Subscriber Name*First name*Sex*MaleFemaleEuropean official*YesNoDate of birth*(DD-MM-YYYY)Nationality*Civil status*Bachelor/SingleCohabitantMarriedWidow(er)SeparatedDivorcedStreet*No.*BoxPostal code*City*E-mail* Telephone*Are you the main driver?*YesNo Main driver NameFirst nameSexMaleFemaleProfessionDate of birthNationalityCivil statusBachelor/SingleCohabitantMarriedWidow/WidowerSeparatedDivorcedStreetNrBoxPostal codeCityE-mail TelephoneDelivery date driving licence*(dd-mm-yyyy)Takeover from insurer in Belgium?*YesNoName of the current insurerNo. of current insurance policyDue date of current policyDid you have any accidents over the last 5 years in third liability (partially or fully responsible)?*YesNoDate of the claimNature of the claimNumber of years without accidents in third liabilityHow many kilometres do you drive per year?Delivery date driving licence(dd-mm-yyyy)Takeover from insurer in Belgium?YesNoName of current insurerNr of your current insurance policyDue date of your current policyDid you had any accidents over the last 5 years in third liability (partially or fully responsible)?YesNoDate of the claimNature of the claimHow many kilometres do you drive per year?Number of years without accidents in third liability Vehicle Brand*Type*Category* Sports car 4x4 Convertible Monovolume Other Fuel*BenzineGasoilLPGHybrid BenzineHybrid GasoilElectricPower in KW*Number of seats (without driver)*Newly bought car*YesNoDriver assistance system*YesNoType of driver assistance system* Parking sensor (front and back) Blind spot monitoring Lane support Automatic Emergency Braking Attention assist Adaptive cruise control First time in traffic date*(DD-MM-YYYY)Catalogue value (without VAT, without equipment)*Catalogue value (without VAT, with equipment)*Anti theft system*VV1VV2VV3SMO1SMO2NoneGuarantees Third liability*CompulsoryOther guarantees Legal assistance Full comprehensive casco Partial casco Driver accident insurance Road assistance Comments All data supplied may be processed by Vanbreda Risk & Benefits for the purposes of customer services, risk acceptance, contract management and claims handling. Such data may be communicated to companies with which they have relations, in order to provide the most suitable services. The individuals concerned consent to the given data being processed to the extent necessary for contract acceptance, management and performance by the handlers acting within the context of the contract. This processing is provided for by the Belgian Privacy Protection Law of December 8, 1992. All information will be handled with the utmost discretion.
