Underwriting form Ambuflex Plus

Name: Vanbreda Risk & Benefits
Price range: $

Fill in the form and we will get back to you.

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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

Language

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 - Billing

E-mail address for sending invoices

Choice of plan design

Preferred starting date

Contact at Vanbreda for implementation

Last name

First name

Position at Vanbreda

E-mail address

Phone number

If you have a current hospitalisation plan, please upload here.

I confirm the following statements:

I confirm having read and understood the information sheet, as well as the policy conditions (Dutch/French) 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 take note of my right to renounce.

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