YOUR DETAILS
Name and first name
Official place of residence
Mail address
Telephone- / mobile-nummer
Social Security Number
TYPE OF CONTRACT
Indicate the type of contract
If this is an acquisition of a contract elsewhere : please specify your current insurance company, your current bonus malus degree and amount of accidents in fault (last 5 years)
DETAILS OF THE VEHICLE TO INSURE
Specify the type of vehicle
Specify the brand and type of the vehicle
Specify the capacity (KW) of the vehicle
Specify the cylinder capacity (CC) of the vehicle
Specify the fuel of the vehicle
Indicate when the vehicle was/will be used for the first time
If the tenderer is a company : enter the VAT number
Optional : enter the license plate number
Optional : enter the chassis number
Indicate the vehicle usage (multiple options possible) Less then 10.000 km a year
Pulls a trailer > 750kg
Home-work traffic
Professional use
Leasing or renting
Enter the purchase value (purchase value incl. VAT, all discounts and options taken into account, except takeover premium old vehicle) euro
In case of leasing : lease amount excl. VAT euro
Only for self-employed : indicate the VAT recovery
Enter all common drivers of the vehicle (name, date of birth and date of driver's license)
Please indicate if you are interested in a quote for one of the following insurances or if we already manage one of these for you Fire insurance
Family insurance
OTHER
Optional : to the attention of
Questions or remarks




Arents & Partners Verzekeringen BVBA

Albertlaan 220, 9400 Ninove

T. 054 32 95 41

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FSMA 042591 A

KBC logo

Verbonden agent, FSMA 042591 A, van KBC Verzekeringen NV, Professor Roger Van Overstraetenplein 2, 3000 Leuven, België BTW BE 0403.552.563, RPR Leuven, IBAN BE43 7300 0420 0601.

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