Underwriting form Ambuflex Plus

Company's information
Company name*
Legal form*
Address registered office:
Street*
Number*
Box
Postal code*
City*
Company number*
Definition of the employees*
Start date company*
DD slash MM slash YYYY
Language contract documents*
Last name signer contract*
First name signer contract*
Job title signer contract*
Company's information - CONTACT PERSON
Last name*
First name*
Gender
Language*
E-mail address*
Phone number*
Company's information - INVOICING
E-mail address for sending invoices*
Choice of plan design
Preferred starting date*
DD slash MM slash YYYY

Dates in the past are not allowed. A contract always starts on the first of the month and at the earliest the following month.
Contact at Vanbreda for implementation
Last name*
First name*
Position at Vanbreda*
E-mail address*
Phone number*
Legal checkbox*
- I confirm the following statements:
- I confirm having read and understood the information sheet, as well as the policy conditions of this product. I confirm that I am sufficiently informed about this product by Vanbreda Risk & Benefits and that this product meets my needs.
- I confirm that I will inform my employees about this insurance and the fact that their personal data are transferred to Vanbreda Risk & Benefits, solely for the purpose of bringing their affiliation to the insurance in order. More information about the privacy policy of Vanbreda Risk & Benefits can be found here.
- I agree to communicate as much as possible via email.
- I take note of my right to renounce.