Contact form BE - Vanbreda

Title*

Mr
Mrs
Ms

First name*

Last name*

Telephone number

Company

E-mail address*

What is your question about?*

I would like to receive a quote to insure a(n) ...*

Which eTool do you want to use?*

eServices
EB Plan
car damage tool

Which insurance does this change apply to?*

hospitalisation insurance
every other insurance

Which type of claim do you want to report?*

car/fire damage
other

You can also report a car damage via our car damage tool.

Subject*

Address*

Street name + number (+ box) Postal code City Country

Telephone number*

Policy number

Date of the damage

Hour of the damage

: HH

MM

Where did the damage occur?

What exactly did happen?

Describe the damage.

Date of birth*

Date of admission to the hospital*

Name of the hospital*

Campus of the hospital

Postal code of the hospital*

City of the hospital*

Reason for the admission (diagnosis/treatment)*

Is the hospitalisation due to an accident?*

yes
no

Date of the accident

Hour of the accident*

: HH

MM

Where did the accident happen?*

How did the accident happen?*

Is it a work related accident?*

yes
no

Has an official report been drawn up?*

yes
no

By whom?

Is a third party involved?*

yes
yes, but unknown
no / not applicable

Name of the third party*

First name Last name

Address of the third party

Street name + number (+ box) Postal code City Country

Insurance company of the third party

Policy number of the third party

New address*

Street name + number (+ box) Postal code City Country

Your message is about a ...*

suggestion
complaint

Type your message here.

Remarks/extra information

Would you like to receive a copy of your message?

yes
no

We only use personal data collected via this contact form for the purpose you have left them. More information on our privacy policy can be found here.

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