Incapacity for work damage declaration

We kindly ask you to complete this form only upon receiving the claim form from our side.

Details employer

Name employer*

Function*

Employment rate (%)

Working hours / week

Personal details

Your name*

First name Surname

Address*

Street House number + addition Municipality Postal code Country

Telephone or mobile number

Member ID

E-mail address*

E-mail address Confirm e-mail address

We recommend to use a private e-mail address.

Date of birth*

National registry number*

Bank details

IBAN*

This is your bank account number that you will find on your bank card and consists of 8 to 11 characters.

BIC

This is a unique identification code of your bank, which you will find on your bank card.

In the name of*

First name * Surname *

Is this a foreign bank?*

No
Yes

Name of the bank*

Address of the bank*

Street House number + addition Municipality Postal code Country

Damage declaration data

Do you have an insurance policy with similar guarantees with another company or organisation?*

No
Yes

Name of other company or organisation*

Address of the third party*

Street House number + addition Municipality Postal code Country

Policy number*

Is your professional income taxable in Belgium?*

No
Yes

What’s your declaration about?*

Disease
Accident
Pregnancy

Details disease

Which condition do you have?*

Did you suffer from any prior disability or illness to the current illness?*

Yes
No

Which disability or illness?

Accident details

What is the nature of the accident?*

Privé
Occupational accident
Competitive sports
Amateur sports

On what date did the accident occur?*

At what time did the accident happen?*

HH * :

MM *

Location of the accident*

Description of the accident*

Description of the injury*

Did you suffer from any other disability or illness before the accident?*

No
Yes

Which one(s)?*

Has an official report been drawn up?*

No
Yes

Name of the authority which drew up the official report*

Address of the authority which drew up the official report*

Street Municipality Postal code Country

Was there a third party involved in the accident?*

No
Yes

Name of the third party*

First name Surname

Address of the third party*

Street House number + addition Municipality Postal code Country

References to civil liability insurance*

Who is responsible for this accident?*

Pregnancy details

Estimated delivery date*

Real delivery date

Attachment(s) *

Attachment(s)*

In order to process your claim we need to receive all documents as indicated in your declaration form. If you do not possess these documents yet, we kindly ask you to wait until they are in your possession.

Attention: Total size of uploaded files is limited to 8 MB.

Drop files here or

Max. file size: 8 MB.

Hidden

Electronic confirmation

I confirm that my answers are complete and truthful. *

I agree to Vanbreda Risks & Benefits's privacy policy and the rights listed in the policy that I as a data subject can exercise, and to the General Terms and Conditions of Health Care Digital and AssurMiFID code of conduct. 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.). *