Subscriber Name*First name*Sex*MaleFemaleEuropean official*YesNoDate of birth*(dd-mm-yyyy)Nationality*Civil status*Bachelor/SingleCohabitantMarriedWidow(er)SeparatedDivorcedStreet*No.*Box*Postal code*City*E-mail* Telephone* Risk to insure Location of risk to insure*Same addressOther addressStreetNo.BoxPostal codeCitySubscriber is*OwnerTenantType of habitation*House (4 sides)House (contiguous)ApartmentApartment on the ground floorYesNoSurface in m²*Building to insure*YesNoContents to insure*YesNoContract taken over from another insurer*YesNoName insurerContract numberDue date of current contractClaims (last 5 years)Date claimCircumstancesRelevant cover Chosen cover Basic cover (1)*MandatoryOptionsTheft*YesNoIndirect claimsYesNoLegal assistance habitation*YesNoThird liability insurance*YesNoPersonsSingle personCouple/FamilyLegal assistance third liabilityYesNo Option theftAlarm system*YesNoKnown systemYesNoConnected to a centralYesNoBurglary resistant doorYesNoInhabitation*RegularVacant >180 nights/year Amounts to cover Contents (estimated value) EUR*Building EUR* The amount of the building to be insured can be calculated on the basis of the characteristics of the building: Number of bathrooms or showers (incl sauna and hammam)*Number of other rooms*(Excluding 1 living, 1 dining room and 1 kitchen)Number of parking lots in the garage*Other rooms and installations Cellar(s) Room(s) with natural stone floor or solid wooden parquet floor (except soft wood) House with natural slate / straw / reed roof Passive house or wood construction Ceilings higher than 3m Floor heating Heat pump Room(s) larger than 70m² Solar cell panel Outdoor swimming pool Comments(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.