Subscriber Name* First name* Sex* Male Female European official* Yes No Date of birth* (DD-MM-YYYY)Nationality* Civil status* Bachelor/Single Cohabitant Married Widow(er) Separated Divorced Street* No.* Box Postal code* City* E-mail* Telephone* Are you the main driver?* Yes No Main driver Name First name Sex Male Female Profession Date of birth Nationality Civil status Bachelor/Single Cohabitant Married Widow/Widower Separated Divorced Street Nr Box Postal code City E-mail Telephone Delivery date driving licence* (dd-mm-yyyy)Takeover from insurer in Belgium?* Yes No Name of the current insurer No. of current insurance policy Due date of current policy Did you have any accidents over the last 5 years in third liability (partially or fully responsible)?* Yes No Date of the claim Nature of the claim Number of years without accidents in third liability How many kilometres do you drive per year? Delivery date driving licence (dd-mm-yyyy)Takeover from insurer in Belgium? Yes No Name of current insurer Nr of your current insurance policy Due date of your current policy Did you had any accidents over the last 5 years in third liability (partially or fully responsible)? Yes No Date of the claim Nature of the claim How 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* Benzine Gasoil LPG Hybrid Benzine Hybrid Gasoil Electric Power in KW* Number of seats (without driver)* Newly bought car* Yes No Driver assistance system* Yes No Type 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* VV1 VV2 VV3 SMO1 SMO2 None Guarantees Third liability* Compulsory Other 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.
