Application ISIS Please fill in the form below to apply for ISIS 1. Insured person First name Last name E-mail address Phone number (optional) Date of birth E-mail address (confirmation) (optional) Gender (optional) Male Female Other Address (optional) Street and house number City Postal code Country Country of origin 2. Policy holder Policy holder (optional) Same as insured person Other Only complete the fields below if the policy holder differs from the insured person. First name (optional) Last name (optional) Date of birth (optional) Phone number (optional) E-mail address (optional) Gender (optional) Male Female Other Address (optional) Street and house number City Postal code Country 3. Desired coverage Start date (optional) End date (optional) Country of origin (optional) Europe Rest of the World Desired coverage (optional) ISIS A ISIS B ISIS C 4. Payment Payment (optional) I would like an invoice Automatic debit Bank account number (optional) I agree with automatic withdrawal If this insurance is taken out by a (commercial) partnership or a legal entity, the final questions also apply to: the members of the partnership; the (limited) partners of the commercial partnership; the (managing) director(s) under the articles of association of the legal entity; the shareholder(s) with an interest of 33.3% or higher and, insofar as these are a legal entity, their (managing) director(s) and shareholders with an interest of 33% or higher. Criminal facts Have you, or any other interested party, in the last eight years been a suspect in, or been prosecuted, convicted or fined for a criminal offence? Yes No If so, please state what the punishable offence was (summary offences are also regarded as a punishable offence), whether the case went to court, what the result thereof was and if any (punitive) measures have already been implemented. If the matter did not go to court, please indicate whether a settlement was reached with the Public Prosecution Service and, if so, on which conditions. If you so wish, you can send this information to our management in confidence. Note: when answering this question, not only the personal knowledge of the applicant/policyholder is decisive, but also that of other interested parties. Details of similar insurance Has any insurer ever cancelled, refused or imposed special conditions on a similar insurance for you? Yes No What reason? (optional) Declaration and signature — important! As applicant/prospective policy holder you are obliged to answer the questions on this application form to the best of your knowledge. You declare that you have taken note of the information and that you would like to obtain the insurance accordingly. The duty to supply information comprises everything that may be relevant for the assessment of the risk and the person(s) applying, including questions to which you think De Goudse may already know the answer. By submitting this form you confirm the above. Leave this empty Submit application We usually respond within one business day. Urgent? Call +31 35 203 1966.
