Onderschrijver Name* First name* Sex* Male Female Date of birth* (dd-mm-yyyy)Nationality* Civil status* Bachelor/Single Cohabitant Married Widow(er) Separated Divorced Profession* Employer* Street* No.* Box* Postal code* City* E-mail* Telephone number* Risk to insure Location of the risk to insure* Same address Other address Street No. Box Postal code City Subscriber is* Owner Tenant Type of habitation* House (4 sides) House (contiguous) Apartment Distance to nearest building > 50m < 50m Apartment on the ground floor Yes No Surface in m²* Building to insure* Yes No Contents to insure* Yes No Thatched house* Yes No Combustible materials* < 20% 20 - 50% > 50% Contract taken over from another insurer* Yes No Name insurer Contract number Due date of current contract New building* Yes No Claims (last 5 years)Date claimCircumstancesRelevant cover Chosen cover Basic cover (1)* Mandatory Theft* Yes No Indirect claims* Yes No Legal assistance habitation* Yes No Option theft Alarm system* Yes No Known system Yes No Connected to a central Yes No Burglary resistant door Yes No Inhabitation* Regular Vacant > 180 nights/year Amounts to cover Contents (estimated value) EUR* Building EUR* Rooms which you should not take into account: The kitchens, bathrooms, rooms smaller than 4m², roof spaces and attics that aren't furnished, uninhabitable annexes (garages excluded) without direct access to the main building. Rooms that you should always take into account: Number of living rooms* (Made up of living, salon and dining room)Number of bedrooms* Number of libraries* Number of offices* Number of porches* Number of sewing or ironing rooms* Number of play rooms* Number of waiting rooms* Number of rooms for liberal profession* Number of garages, even those without direct access to the main building (count the number of parking spots in the garage(s))* Rooms that you should take into account if they are located elsewhere than in the cellar, that is, under the level of the main entrance: Number of laundry rooms* Number of boiler rooms* Number of hobby rooms* Number of storage rooms* TotalCommentsThe system should under no circumstance be used for single-family homes with a lift, nor for buildings with an inside or covered swimming pool or for buildings with more than 13 rooms. Empty rooms, at the time the inventory is made, should be labelled according to their previous or future uses. Not every change to the use of invertorised rooms should be reported, only the addition of more rooms of a kind that was already listed.(1) The basic cover contains among others: fire, explosion, smoke and grime, storm, hail, snow and ice pressure, break of glass, water damages, lightning strike... 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.