Please answer the following questions about your contract, date settings and desired insurance coverage. Advisor: International Insurance, Postbus 150, 2810 AD Reeuwijk. Contract number: 3525
Language of preference —Kies een optie—EnglishDutch
Start date
Please complete the following questionnaire. Accurately fill in your name as it should appear on your policy as well as gender and Date of Birth, and address including house number. If you don’t know your Dutch address yet, please use the address of our office (Postbus 150, 2810 AD Reeuwijk).
Initials (first letter of first name)
Inserts (between given name and last name like ‘van or von’)
Last name (family name)
Date of birth
Gender —Kies een optie—MaleFemale
Address
House number (just enter your house number, for example 105 or 1B, not your phone number)
Zip code
City
To complete your request, please leave your contact information along with your bank account number. By clicking 'submit' you accept that your account number will be used for the payment of your insurance by direct debit.
E-mail
Phone number, including country code
In order to complete your request please provide your financial account information. By Clicking “Submit” you acknowledge this will be the primary account the payment will be debited from. Choice of payment*: direct debit.
IBAN
A A Dutch IBAN number is required to set up your account. If you do not yet have a Dutch IBAN please let the field blank. We will send to you a payment link.
