Agency Allianz - Franck Haloche

Agency Allianz - Franck Haloche

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Call now for a FREE quote on: 033 (0)2 43 05 21 82

Health insuranceHealth Insurance Form

To receive a quotation for Health Insurance, please fill in the following details and click SEND. We will then respond to you as soon as possible.

     
Your Name:
 
Address:
 
Telephone:
 
Email Address:
 
Name of Person to be insured:  
Date of Birth:  
Social Security Number:
(if known)
 
     
COVER REQUIRED    
General Care  
Hospital  
Dental / Orthodontist  
Optical  
Hearing Aid  
Homeopathy  
Alternative Medicine
(osteopath, dietician, acupuncturist ...)
 
  The coverage level can be different for each family member. Please use the form again for each person.  
     
How did you hear about us?  
     
Discount Code:  
     
Quotation in French only?  
     
 
 
Please call us on 0033 (0)2 43 05 21 82 if you have any problem with this form
     
   
     

 

Agency Allianz - Franck Haloche

1 rue Louis Blériot
Parc d’activités des Sémondières
53500 ERNEE
France


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Tel: 0033 (0)2 43 05 21 82
EMail: 4005417@agents.allianz.fr