SubscriberName*First name*Gender*MaleFemaleProfession*Employer*Date of birth*(DD-MM-yyyy)Nationality*Civil status*Bachelor/SingleCohabitantMarriedSeparatedDivorcedWidow(er)Street*No.*BoxPostal code*City*Telephone number*E-mail* Are you the main driver?YesNo Main driver NameFirst nameGenderMaleFemaleDate of birth(dd-mm-yyyy)NationalityCivil statusBachelor/SingleCohabitantMarriedSeparatedDivorcedWidow(er)StreetNo.BoxPostal codeCityE-mail Telephone numberDelivery date driving licence*(dd-mm-yyyy)Current bonus malus*Takeover from insurer in Belgium?*YesNoName of current the insurerNo. of current insurance policyDue date of current policyDid you have any accidents over the last 5 years?*YesNoDate of claim (not your fault)Date of claim (your fault)Date theft or attempt at theft How many kilometres do you drive per year?* VehicleBrand*Type*Kind of vehicle*CarMotorbikeVanProperties Sports car 4x4 Convertible Monovolume CCBusiness useYesNoFuel*BenzineGasoilLPGHybrid BenzineHybrid GasoilElectricPower in KW*Number of seats (without driver)*Newly bought car*YesNoDriver assistance system*YesNoType of driver assitance system Parking sensor (front and back) Blind spot monitoring Lane support Automatic Emergency Braking Attention assist Adaptive Cruise Control First time in traffic date*(DD-MM-yyyy)Catalogue value (Without VAT, without equipment)*Invoice value (Without VAT, without equipment*Amount equipment (Without VAT)*Insure tax on entry into service*YesNoAnti theft system*VV1VV2VV3SMO1SMO2NoneTrailer > 750 kg*YesNoProfessional use*YesNo Guarantees Third liability*CompulsoryOther guarantees Legal assistance Full comprehensive casco Partial casco Driver accident insurance Assistance Installment payment of premium*AnnualEvery three monthsEvery six monthsChosen Own Damage excemptionCommentsAll 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.