DEMO
Insurance Application
Personal Information
Insurance Coverage
Previous Insurance & Claims
Summary
Please correct the following errors:
Personal Information
Last Name
First Name
Street
House Number
Postal Code
City
Date of Birth
Phone Number
Email Address
Please correct the following errors:
Insurance Coverage
Tariff Selection
Basic Tariff
Premium Tariff
Tariff Option
Single
Couple
Family
Payment Frequency
Yearly
Quarterly
Monthly
Deductible:
0€
150€
The premium based on your selection is:
100€
Please correct the following errors:
Previous Insurance & Claims
Have you had personal liability insurance in the past 5 years?
Yes
No
Previous Insurer
Contract Number
End Date
Have any claims been reported in the past 5 years?
Yes
No
Please provide details
Data Protection & Signature
I have read the data protection policy and agree.
I accept the terms and conditions.
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