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Household Quote Request

CLIENT DETAILS

NIE Nº

NAME

ADDRESS

Apartment, suite, etc.

CITY

STATE/PROVINCE

ZIP/POSTAL CODE

COUNTRY

TELEPHONE

MOBILE

EMAIL

DATE OF BIRTH

NATIONALITY

PROPERTY TO BE INSURED

PROPERTY TO BE INSURED

ADDRESS

Apartment, suite, etc.

CITY

STATE/PROVINCE

ZIP / POSTAL CODE

COUNTRY

PROPERTY TYPE / TIPO DE PROPIEDADVILLATOWNHOUSE / ADOSADAOTHER / OTROAPARTMENT / APARTAMENTOGROUND FLOOR / BAJOPENTHOUSE / ÁTICO

WHICH FLOOR *

YEAR OF CONSTRUCTION

TOTAL CONSTRUCTRED AREA(m2)

BUILDINGS(m2)

GARDEN(m2)

SECURITY

ALARM WITH LINE TO CENTRAL STATIONALARM WITH LINE TO CENTRAL STATION

OTHERS

USE OF PROPERTYOWNERTENANTMAIN RESIDENCEHOLIDAY HOMELONG TERM RENTALSHORT TERM RENTALNOTE: if the property is not left vacant for more than 6 consecutive months please tick main residence.

SUMS INSURED

BUILDING

EUR

CONTENTS

EUR

JEWELLERY

EUR

OBJECTS OF VALUE (ART, ANTIQUES, RUGS, ETC.)

EUR

Details of any losses over past 5 years (including cause, date and amount settled by previous Insurer)

Consent *

I accept the privacy policy and terms and conditions.

I agree to receive commercial communications from Op de Beeck & Worth

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If you have any question, please do not hesitate to contact directly Op de Beeck & Worth at alex@opdebeeck-worth.com refering as EPAM employee.