Underwriting form

Company name*

Legal form*

Address registered office:

Street*

Number*

Box

Postal code*

City*

Country*

Company number*

Number of employees*

Start date company*

Language contract documents*

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*

Dates in the past are not allowed.

Hospitalisation insurance

Legal checkbox*

I confirm having read and understood the information sheet, as well as the policy conditions of this product.
I give my consent to SD Worx to pass on all personal information relating to my employees and strictly necessary within the framework of this insurance to Vanbreda Risk & Benefits. I confirm the correctness of that data and agree to keep it up-to-date at all times.
I confirm that I will inform my employees about this insurance and the fact that their personal data are transferred via SD Worx to Vanbreda Risk & Benefits, solely for the purpose of bringing their affiliation to the insurance in order. More information about the privacy policy of Vanbreda Risk & Benefits can be found here.
I agree to communicate as much as possible via email.
I take note of my right to renounce.