Aon Health RFQ - Courtage d`assurances et de réassurances

French Health Insurance Request for Quote
Where did you hear about us?
Web Search (please
Print ad or mailing (please
specify search engine in
Details box)
Persons to
specify publication or Priority Code
in Detail box)
First name
insure
Details:
Link or ad from another
website (please specify website
in Details box)
Reffered by a friend of
relative (please specify Customer ID
in Details box)
Last name
Other
(please specify)
Birth Date (dd/mm/yyyy)
You
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Your spouse/significant other
_
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Child 1
_
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Child 2
_
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Child 3
_
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Country of citizenship
Country of residency
Your stay in France
Exact date of arrival in France
(dd/mm/yyyy) _
_/_
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End of stay / of coverage
Coverage starting date (if different from date of arrival):
Duration:
(dd/mm/yyyy) _
_/_
_/_
_
(dd/mm/yyyy) _
_/_
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Temporary stay. Please specify exact duration in days, weeks of months:
Annual stay (at least one year, renewable). Please specify number of years:
Reason:
Professional stay. Please specify position
Gross annual income
€
Private or recreational
Contact information
Your address in France
Postal Code
Town
Telephone number
E-mail address
Medical information
Please summarize, for each person to insure, known medical conditions and treatments, both current and expected while in France.
This data (your information) is meant to be dealt with and processed by Aon Conseil & Courtage in order to provide a
quote. You have a right of access, modification, rectification and deletion on your information (French "Informatique et
Libertés" Act of 6 January 1978). For any query, please contact [email protected]
Please return completed form
by fax:
or mail:
+33(0)-158-758-067
Aon Insurance for Expatriates
45 rue Kleber
92697 Levallois Perret Cedex France
•
In France, call toll free
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Outside of France:
+33-495-061-646
[email protected]
www.AonInsureXpat.com
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Aon Conseil & Courtage Société de courtage en assurances et réassurances immatriculée au Registre Unique des Intermédiaires d’Assurances sous le n° 07 001 560
SA au capital de 4 141 334 euros - 414 572 248 RCS Nanterre - Siège social : 45, rue Kléber - 92697 Levallois-Perret cedex Tél. 33 (0)1 58 75 75 75 - Fax 33 (0)1
58 75 77 77 - www.aon.fr - N° de TVA intracommunautaire : FR 22 414 572 248 GARANTIE FINANCIÈRE ET ASSURANCE DE RESPONSABILITÉ CIVILE
PROFESSIONNELLE CONFORMES AUX ARTICLES L512-7 ET L512-6 DU CODE DES ASSURANCES
A 003 14 11 00 00 Mai 2006