SubscriberName* First name* Street* No.* Box* Postal code* City* Sex* Homme Femme Language* English Dutch French Date of birth* (dd-mm-yyyy)Nationality* E-mail* Telephone* Secondary residence* Yes No Address secondary residence Street No. Box Postal code City Formula Formula* Gold Silver Start date contract* (dd-mm-yyyy) Antecedents Did the insured already subscribe for an insurance legal assistance?* Yes No Insurance company Policy number Was this insurance cancelled because of a claim? Yes No Were the insured involved in more than one claim during the last 5 years? Yes No Was a legal assistance coverage refused by another insurance company? Yes No 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.
