Personal information Name* First name* Street* No.* Box City* Postal code* Telephone No.* E-mail* Items Nature of itemDescriptionArtistValue (€) Total Make your choice Please provide a policy for the aforementioned items at a premium* of The total value I wish to insure is in excess of 200,000 EUR or the value of one item is in excess of 12,500 EUR. I would like to call upon your art expert (15 items free of charge). I would like to insure jewellery as part of the value accepted and therefore wish to call upon your art expert. I would like to call upon your art expert for a free valuation. Comments* premium based on All Risks terms and conditions including theft, loss and breakage / different taxes applicable in Luxembourg (4%)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.