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* Risk to insure Location of 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 Apartment on the ground floor Yes No Surface in m²* Building to insure* Yes No Contents to insure* Yes No Contract taken over from another insurer* Yes No Name insurer Contract number Due date of current contract Claims (last 5 years)Date claimCircumstancesRelevant cover Chosen cover Basic cover (1)* Mandatory OptionsTheft* Yes No Indirect claims Yes No Legal assistance habitation* Yes No Third liability insurance* Yes No Persons Single person Couple/Family Legal assistance third liability Yes No Option theftAlarm 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* 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.