• Achternaam
• Geslacht
  -MannelijkVrouw
• Address and n°
• Stad

• Telefoon (thuis)
• Office telephone n°
• Bent u al klant van VDV CONSEIL PLC?
  -GeenJa

• Achternaam
• Geslacht
  -MannelijkVrouw
• Address and n°
• Stad
• Nationaliteit
• Date of issue of driver's licence

• Achternaam
• Geslacht
  -MannelijkVrouw
• Date of issue of driver's licence (dd/mm/yyyy)
• Postcode
• Beroep
  -Blue-collar workerWhite-collar workerSelf-employedState employeeServiceman or womanDisabled personUnemployedRetiredUnemployed

• Type (car, small van, motorbike, moped etc.)
• Make
• Serial or version
• Chassis n°
• Capacity
• Petrol
• Catalogue value with options excl. VAT (excluding discounts/reductions)
• Number of seats (excluding driver)
• Age of vehicle
  -Vehicle is 24 months old maximumVehicle is 25 months or older
• Number of kilometres covered per year
  -maximum 2.500 kmmaximum 5.000 kmmaximum 7.500 kmmaximum 10.000 kmmaximum 12.500 kmmaximum 15.000 kmmore than 15.000 km
• There is a remorque ?
  -GeenJa

• Other cover required

• Are you (or have you been) insured and/or included as a "usual or non-usual driver" with a company in a contract, whatever this may be (in your name or in an employer's name or other)?
  
  Already insured
  -GeenJa
  
  
  • Met welk bedrijf?
  • Contract number
  • Maturity date of contract
  • Current no-claims bonus level
  • Are you able to provide us with a claims record certificate for this insurance (certificate provided by the insurer at the end of every insurance contract)?
    -GeenJa
  • Yes. How many years does this certificate cover?
    -0 year1 year2 years3 years4 years5 years and +
• Are you already insured with AXA BELGIUM and/or AG INSURANCE (ex FORTIS AG) by way of a car or fire insurance?
  
  
  -GeenJa
  
  
  • Please specify the contract number
  • Please specify the contract number
  • Please specify the contract number
• Is a member of your family (spouse, child) already insured with AXA BELGIUM and/or AG INSURANCE (ex FORTIS AG) by way of a car or fire insurance?
  
  
  -GeenJa
  
  
  • Please specify the contract number
  • Please specify the contract number
  • Please specify the contract number

• Ik wil graag betalen:
  -JaarlijksHalf-yearly (+2%)Quarterly (+3%)Monthly (with compulsory domiciliation)

Comments or particular remarks:

• Deze informatie wordt op vertrouwelijke basis verstrekt; u kunt ons echter toestemming geven om uw e-mailadres te gebruiken om op de hoogte te blijven van ontwikkelingen en promoties bij VDV Conseil.