• Surname
• Gender
  -MaleFemale
• Address and n°
• Town

• Telephone (home)
• Office telephone n°
• Are you already a VDV CONSEIL PLC client?
  -NoYes

• Surname
• Gender
  -MaleFemale
• Address and n°
• Town
• Nationality
• Date of issue of driver's licence

• Surname
• Gender
  -MaleFemale
• Date of issue of driver's licence (dd/mm/yyyy)
• Postal code
• Occupation
  -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 ?
  -NoYes

• 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
  -NoYes
  
  
  • With what company?
  • 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)?
    -NoYes
  • 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?
  
  
  -NoYes
  
  
  • 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?
  
  
  -NoYes
  
  
  • Please specify the contract number
  • Please specify the contract number
  • Please specify the contract number

• I would like to pay:
  -AnnualHalf-yearly (+2%)Quarterly (+3%)Monthly (with compulsory domiciliation)

Comments or particular remarks:

• This information is given on a confidential basis; you may however authorise us to use your e-mail address to be kept informed on developments and promotions at VDV Conseil.