Underwriting form Company's informationCompany name* Legal form* Address registered office:Street* Number* Box Postal code* City* Country* Company number* Number of employees*Start date company* DD slash MM slash YYYY Language contract documents*ChooseDutchFrenchEnglishLast name signer contract* First name signer contract* Job title signer contract* Company's information - CONTACT PERSONLast name* First name* Gender*ChooseMaleFemaleLanguage*Selecteer een optieDutchFrenchEnglishE-mail address* Phone number* Company's information - INVOICINGE-mail address for sending invoices* Choice of plan designPreferred starting date* DD slash MM slash YYYY Dates in the past are not allowed.HiddenHospitalisation insurance Hospitalisation insurance Legal checkbox* I confirm the following statements: I confirm having read and understood the information sheet, as well as the policy conditions of this product. Please note that our policy conditions are not available in English. You can view them in either Dutch or French. 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.
