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.

 POLICYHOLDER DETAILS
Full Name:
 
Address in France:
 
Date of Birth:  dd/mm/yyyy  
Occupation:  
Email Address:
 
Telephone:
 
Are you already insured in France?
If so, with which company?
 
     
Please indicate the following information on the people who you would like to insure also on the insurance policy. If you are more than 4, please contact us:
 PERSON 1
Full name:  
Date of Birth:  dd/mm/yyyy  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
 PERSON 2
Full name:  
Date of Birth:  dd/mm/yyyy  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
 PERSON 3
Full name:  
Date of Birth:  dd/mm/yyyy  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
 PERSON 4
Full name:  
Date of Birth:  dd/mm/yyyy  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
     
 COVER
Hospitalization only (You will only be covered for hospitalization in your insurance package)  
Hospitalization  
General care (general or specialist consultations, X-Rays …)  
Dental / Orthodontist BASIC (You need cover for basic dental: cleaning, filling, general checkups …)  
Dental / Orthodontist MAX (on top of the basic cover, you need: dentures, crowns, bridges, implants …)  
Optical (You need cover for glasses, frames, contact lenses)  
Homeopathy  
Alternative Medicine (Chiropodist, Dietician, Acupuncturist, Osteopath, Chiropractor…)  
     
How did you hear about us?  
     
I am interested in receiving more information on your full insurance packages  
     
 
     
 
 
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