SubscriberName*First name*Street*No.*Box*Postal code*City*Sex*HommeFemmeLanguage*EnglishDutchFrenchDate of birth*(dd-mm-yyyy)Nationality*E-mail* Telephone*Secondary residence*YesNo Address secondary residence StreetNo.BoxPostal codeCity Formula Formula*GoldSilverStart date contract*(dd-mm-yyyy) Antecedents Did the insured already subscribe for an insurance legal assistance?*YesNoInsurance companyPolicy numberWas this insurance cancelled because of a claim?YesNoWere the insured involved in more than one claim during the last 5 years?YesNoWas a legal assistance coverage refused by another insurance company?YesNo 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. CAPTCHA
