Acceptance PolicyYou can digitally accept the quote offered using the form below.Digital Acceptance PolicyYou can use this form to digitally approve the quote offered.Desired start date MM slash DD slash YYYY Quotation numberEmail address* Telephone*You agree to the digital sending of documents Yes NoThis includes: The policy The invoice The insurance card (Green Card)Do you have a Dutch driving license? Yes NoHave you ever been denied a driving license? Yes NoIf yes, please explainAre there any notes on your driver's license? Yes NoIf yes, please explainAre you limited in your driving ability due to a disability or the use of medication? Yes NoIf yes, please explainHave you suffered any damage in the past 5 years? Yes NoIf yes, please explainPremium payment via: Payment slip Direct debitPremium payment per Year Quarterly (5% surcharge, expires with direct debit) Half year (3% surcharge, expires with direct debit) Month (direct debit required)You must sign the standing order for monthly premium payments or if you have chosen direct debit as your payment method. By signing this form, you give permission to the insurer to send standing orders to your bank. You also give permission to your bank to continuously debit an amount from your account. If you do not agree with this debit, you can have it reversed. To do this, contact your bank within 8 weeks of the debit. Ask your bank for the conditions.IBANInsurance is a matter of trust. In order to insure you properly, we need to know you well as a customer and we need information from you in order to be able to assess the risk. This also concerns information from or about stakeholders in the insurance. In this context, we understand stakeholders to mean: applicant, policyholder and insured. Please answer the following questions:denied insurance?* Yes NoIf yes, please explaincancelled an insurance policy?* Yes NoIf yes, please explainan insurance offered under limited or special conditions?* Yes NoIf yes, please explaina claim rejected in whole or in part?* Yes NoIf yes, please explainDamages claimed in connection with false statement?* Yes NoIf yes, please explainHave you or another interested party in this insurance been in contact with the police or the judiciary in connection with criminal offences in the last 8 years? This also includes, for example, a dismissed case, acquittal, imposition and execution of a sentence.* Yes NoCriminal past:* Yes NoIn the previous question you indicated that you or another interested party in the insurance application has a criminal record. Please answer the following questions: Have you or another interested party in this insurance been in contact with the police or the judiciary in the last 8 years as a suspect or in execution of an imposed sentence or measure in connection with criminal offences such as: • unlawfully obtained or obtainable benefits such as theft, receiving stolen goods, embezzlement, fraud, swindling, forgery; • unlawful harm to others such as destruction or damage, arson, extortion and threats; • any crime against personal freedom such as assault, sexual assault, rape, indecent acts with minors, possession of child pornography, etc. or crimes against life (murder, manslaughter); • crimes relating to the possession of and trading in weapons and/or ammunition; • drug offences such as the possession, cultivation, trading in, transit or import of drugs; • environmental crimes or crimes as punishable under the Economic Offences Act; • traffic offences such as driving under the influence, driving on after a collision, driving while banned from driving or while disqualified from driving motor vehicles; • money laundering of financial resources obtained through crime; • committing or aiding and abetting identity fraud, fraud with (social) insurance, internet fraud, tax fraud or other forms of fraud; • crimes related to terrorism; • participation in a criminal organisation; • punishable attempt to commit one or more of the above-mentioned criminal offencesWhat was the crime?Please provide further explanation of the outcome (conviction, dismissal, dismissal of prosecution, acquittal, settlement).Have any (punitive) measures been imposed and in what period were they implemented?The undersigned declares: • to have answered and provided the above questions and information to the best of his/her knowledge, correctly and truthfully, and not to have withheld any details relating to this application; • to issue this application, and any information still to be provided to the insurer/underwriter, in order to obtain the requested insurance;Do you have any additions or wishes?NameThis field is for validation purposes and should be left unchanged.
