Underwriting form Hospi via Payroll

Company's information

Company name

Legal form

Street

Number

Box

Postal Code

City

Company registration number

Number of employees

Start date company

Contract documents language

Last name signer contract

First name signer contract

Job title signer contract

Last name

First name

Gender

Language

E-mail address

Phone number

E-mail address for sending invoices

Preferred starting date

Please note: This date cannot be back dated, always starts on the first of the month and at the earliest the following month.

I confirm having read and understood the information sheet, as well as the policy conditions (Dutch/French) of this product. I confirm that I am sufficiently informed about this product by Vanbreda Risk & Benefits and that this product meets my needs.
I hereby authorize SD Worx to transmit any personal data of my employees that are strictly necessary within the context of this insurance to Vanbreda Risk & Benefits. I hereby confirm the accuracy of such information and agree to keep it updated at all times.
I also confirm that I will notify my employees regarding this insurance and the fact that their personal data will be passed on via SD Worx to Vanbreda Risk & Benefits, for the sole purpose of being able to manage their enrolment for the insurance cover that has been arranged. More information about the privacy policy of Vanbreda Risk & Benefits can be found here.
I take note of my right to renounce.

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