Allianz Thierry Marcq - Insurance and Finance in English
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Please complete this form or call us on :
00 33 (0)3 21 11 17 10
Number of adults to be insured
*
:
1
2
Number of children to be insured
*
:
0
1
2
3
4
5
Adult 1
First name
*
:
Last name
*
:
Email
*
:
Phone :
Postcode
*
:
City
*
:
What is your date of birth ?
*
:
(DDMMYYYY)
Do you wish to limit your cover to hospitalisation only ?
Yes
No
Do you regularly consult specialists ?
Yes
No
If yes, does s(he) exceed the fixed fees ?
Yes
No
I don't know
Do you require cover for glasses/lenses ?
Yes
No
If yes, what is the approximate replacement cost of your glasses/lenses ?
< 100 Euros
100 - 200 Euros
200 - 300 Euros
> 300 Euros
If yes, how often on average do you replace your glasses/lenses ? :
Annually
Every 2 years
Every 3 years
Every 4 years or more
Do you want to cover dental care ?
No
Yes, regular check ups
Yes, check ups, crowns, prostheses
Do you require cover for alternative medicine (acupuncture, osteopathy) ?
No
Yes
Adult 2
First name
*
:
Last name
*
:
Date of birth ?
*
:
(DDMMYYYY)
Do you wish to limit your cover to hospitalisation only ?
Yes
No
Do you regularly consult specialists ?
Yes
No
If yes, does s(he) exceed the fixed fees ?
Yes
No
I don't know
Do you require cover for glasses/lenses ?
Yes
No
If yes, what is the approximate replacement cost of your glasses/lenses ?
< 100 Euros
100 - 200 Euros
200 - 300 Euros
> 300 Euros
If yes, how often on average do you replace your glasses/lenses ? :
Annually
Every 2 years
Every 3 years
Every 4 years or more
Do you want to cover dental care ?
No
Yes, regular check ups
Yes, check ups, crowns, prostheses
Do you require cover for alternative medicine (acupuncture, osteopathy) ?
No
Yes
Children 1
First name
*
:
Last name
*
:
Date of birth ?
*
:
(DDMMYYYY)
Children 2
First name
*
:
Last name
*
:
Date of birth ?
*
:
(DDMMYYYY)
Children 3
First name
*
:
Last name
*
:
Date of birth ?
*
:
(DDMMYYYY)
Children 4
First name
*
:
Last name
*
:
Date of birth ?
*
:
(DDMMYYYY)
Children 5
First name
*
:
Last name
*
:
Date of birth ?
*
:
(DDMMYYYY)
For the children
Do you wish to limit your cover to hospitalisation only ?
Yes
No
Do you regularly consult specialists ?
Yes
No
If yes, does s(he) exceed the fixed fees ?
Yes
No
I don't know
Do you require cover for glasses/lenses ?
Yes
No
If yes, what is the approximate replacement cost of your glasses/lenses ?
< 100 Euros
100 - 200 Euros
200 - 300 Euros
> 300 Euros
If yes, how often on average do you replace your glasses/lenses ? :
Annually
Every 2 years
Every 3 years
Every 4 years or more
Do you want to cover dental care ?
No
Yes, regular check ups
Yes, check ups, crowns, prostheses
Do you require cover for alternative medicine (acupuncture, osteopathy) ?
No
Yes
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