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

*

*

Vanbreda Risk & Benefits NV will act as data controller and process the information received for the purposes of complying with its legal obligations, maintaining customer service levels, managing your contracts and claims, and paying insured values. This information may be shared with insurers and experts involved in the assessment of your case. You can find more information about our privacy policy and your rights at www.vanbreda.be/en/privacy.*