Private life accident plan Form
Paul BOUSSARD - ALLIANZ
About you as policyholder
Title
Mr
Mrs
First name
Surname
Your date of birth
-
Mois
-
Jour
Année
Date
Your address
Your email address
Your phone number
Your nationality
Your family situation
Single
Married
Partened
Widow
Your occupation
Employed
Self-employed
Retired
Other
Kids
Yes
No
Retour
Suivant
Persons to insure
You
Yes
No
Your spouse or partner ?
Yes
No
If yes ?
First name
Surname
Date of birth
-
Mois
-
Jour
Année
Date
Kids
Yes
No
If yes, how many ?
In your family, you or someone practices a dangerous sport*
Yes
No
* Dangerous sport : underwater, aerial, car or motorbike competitions
Soumission
Should be Empty: