Declaration of hospitalisation

Personal data patient

First name*

Last name*

Telephone number

E-mail address*

Enter Email Confirm Email

Date of birth*

Date of admission to the hospital*

One day clinic*

Emergency hospitalisation*

Hospitalisation abroad*

Province of the hospital*

Hospital*

Reason for the admission (diagnosis/treatment)*

Not found in the list ? Please describe the admission reason as detailed as possible below.

Additional info (diagnosis/treatment)*

Is the hospitalisation the result of a fall or an accident? (private accident, school accident, work related accident, sports accident, ...)*

Date of the accident*

Hour of the accident*

Where did the accident happen?*

How did the accident happen?*

Is it a work related accident?*

Has an official report been drawn up?*

By whom?

Is a third party involved?*

Name of the third party*

First name Last name

Address of the third party

Street name + number (+ box) Postal code City Country

Insurance company of the third party

Policy number of the third party

*

*

I agree to Vanbreda Risks & Benefits's privacy policy and the rights listed in the policy that I as a data subject can exercise. This data, including my health data, may be processed by Vanbreda Risk & Benefits for the purposes of customer service, accepting risks, managing contracts and claims, making insurance related payments, and the proper functioning of their services. If it is required to execute this agreement or if they obliged to do so by law, Vanbreda Risk & Benefits may forward my personal data to third parties (insurers, experts, monitoring doctors, etc.). *