-
I the undersigned ____________________ Usual / married name
______________________________ First name(s)
______________________________
DOB in _________________________________________________________
Nationality ________________________________
Sex: ☐ F ☐ M
Marital status: ☐ single ☐ married ☐ widow ☐ divorced ☐ marital
life ☐ civil unionAddress in France:
______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Address in country of origin:
_______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Phone: ______________________________ E-mail:
____________________________________________
Passport n°: ________________________________
• request membership of the individual « health » coverage
schemes☐ for myself alone, ☐ for myself and my family of which the
beneficiaries are as follows :
Kinship Sex (M or F)
Family name First names DOB (dd/mm/yyyy)
Spouse1st child2nd child3rd child4th child
☐ F ☐ M☐ F ☐ M☐ F ☐ M☐ F ☐ M☐ F ☐ M
_________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________
Health cover (only one choice possible) Annual contribution
1
___________________ €Coverage level :
- Expatriate insurance plan ☐ * ☐ ** ☐ ***- Health cover 1st € -
Coverage area France and European Economic Area excluding the
United Kingdom
• request membership of the Assistance and Civil Liability
coverage
Assistance and Civil Liability Annual contribution 2
Coverage area Worldwide except USA, Canada, Switzerland, Israel,
Japan, Hong Kong and SingaporeAssistance cover ☐ yes ☐ no
___________________ €Civil liability ☐ yes ☐ no ___________________
€
Globe Partner Association - Individual Membership Application -
ACS France
Beyond the 4th child please submit the information on a separate
sheet of paper. For children over 20 years old, a school attendance
certificate must be provided.
☐ ****
A C S – I N SURANC E B ROK E RAGE
COMPANY 1 5 3 RU E D E L ’ UN I V E R S I
T E 7 5 0 0 7 P A R I S – F r a n c e
T E L + 3 3 ( 0 ) 1 4 0 4 7
9 1 0 0
Email : contact@acs‐ami.com Web site : www.acs‐ami.com
317 218 188 RCS Paris –S.A.S (Simplified joint‐stock company)
with a share capital of 150 000 € N° ORIAS 07 000 350 (www.orias.fr) In case of a complaint, please write to ACS Complaint Service at our postal address. ACS is controlled by the ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09 France
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http://www.acs-ami.com/enhttp://www.acs-ami.com/enmailto:[email protected]
-
• request membership of the individual Contingency coverage
Contingency (only one choice possible) Annual contribution 3
Gross annual income in Euro (if contingency coverage)
__________________________€
1 - Death option ☐ Essential (25 000 €) ☐ Comfort (50 000 €) ☐
Excellence (100 000 €) __________________ €(complementary to health
cover - cannot exceed two times the stated gross annual income)
Beneficiary designation in the event of death☐ 1st formula : I
choose the type designation below :In the event of death, the lump
sum shall be paid to : the no separated spouse of married policy
holder, the civil union partner or cohabitant, or failing, to the
children born or to be born of the policy holder, In equal shares
between them, the predeceased share being allotted to his own
children or brothers and sisters if he or she has no children,
failing, the father and mother in equal fractions, the
precedeceased’s share being paid to the survivor, or failing, the
heirs.
☐ Essential (Benefits 25€/day) ☐ Comfort (Benefits 50€/day) ☐
Excellence (Benefits 100 €/day) __________________ €(complemetary
to death option - cannot exceed 70 % of the stated gross annual
income)
Scheme 1st €
Grace period ☐ 90 days ☐ 180 days
The amount of my first annual contribution for Health (1) +
Assistance (2) + Contingency (3) is _________________ € Annual
contribution 4
I want my membership to become effective on
Contributions are payable in advance. Annual Globe Partner
Association membership costs: 20 € per contract.
Payment method : ☐ debit of credit card ☐ bank transfer ☐ cheque
☐ standing orderFrequency : ☐ calendar year ☐ calendar half-year ☐
calendar quarter year ☐ month
payable to ACS, corresponding to the premium pro rated to time
between the effective date and the first Instalment : I settle the
amount of EUR ___________calendar insurance period + EUR 20
membership fees by :
☐ debit of credit card ☐ bank transfer ☐ cheque ☐ standing
order
In ___________________________________ on
References of broker
_________________________
☐ 2nd formula : I do not opt for the 1st formula and designate
as my beneficiary
______________________________________________________________
______________________________________________________________________________________________________________________________
By choosing this formula, the Insured shall provide several
successive beneficiaries and if he wants an exact distribution
between each beneficiary, indicate the share for each of them by
ending with «failing, my heirs». If no option is chosen, the first
1st formula is applied.
2 - Disability option
Globe Partner Association - Individual Membership Application -
ACS France
Read and approved
______________________Signature
A C S – I N SURANC E B ROK E RAGE
COMPANY 1 5 3 RU E D E L ’ UN I V E R S I
T E 7 5 0 0 7 P A R I S – F r a n c e
T E L + 3 3 ( 0 ) 1 4 0 4 7
9 1 0 0
Email : contact@acs‐ami.com Web site : www.acs‐ami.com
317 218 188 RCS Paris –S.A.S (Simplified joint‐stock company)
with a share capital of 150 000 € N° ORIAS 07 000 350 (www.orias.fr) In case of a complaint, please write to ACS Complaint Service at our postal address. ACS is controlled by the ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09 France
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http://www.acs-ami.com/enhttp://www.acs-ami.com/enmailto:[email protected]
-
Individual membership application - About your personal
information
The information collected by ACS, insurance broker, simplified
joint-stock company registered under number 317 218 188 RCS Paris,
and located at 153, rue de l’Université – 75007 Paris, France,
either directly from you or via your insurance intermediary, is
subject to data processing for the sole purpose of:
• preparing, concluding, managing and executing your quote or
contract (study of needs, underwriting, calculation and collect of
premium, preparation of endorsements, claims management, treatment
of complaints if any…),
• enforcing regulations related to anti-money laundering and
terrorist financing prevention, fight against fraud,• elaborating
statistical and actuarial studies,• redistributing risks via
reinsurance or coinsurance.
They will be retained 3, 5 or 10 years in accordance with
applicable laws and regulations.
The processing of such data is carried out in compliance with
the requirements applying to the collection, processing, recording,
organization, purpose limitation and data minimization, storage,
adaptation or alteration, retrieval, consultation, use, disclosure
by transfer, dissemination, security of personal data.
The recipients of such data are, within the limits of their
relevant assignments and according to applicable purposes, the
insurers, reinsurers, insurance intermediaries (your direct broker,
if applicable), and eventually their subcontractors, which
intervene in the context of the execution or the management of your
contract, third party administrators, the mediator if a case is
submitted to him/her, authorities legally authorized to manage your
complaints, Tracfin for the fight against terrorism and anti-money
laundering. Your data may also be transmitted to any person
benefiting from the contract (subscriber, insured, member, and
beneficiary of the contract).
You expressly accept the collection and processing of data
concerning your health. This information is necessary for the
execution and the management of your contract and your benefits,
which is the sole purpose of the processing, and made in accordance
with the regulations of medical confidentiality. This information
is exclusively intended for the medical advisors of ACS, its
departments in charge of managing your benefits, its third-party
administrators and assistance providers if applicable, as well as
for the insurers and reinsurers of your contract.
In addition, we inform you that your personal data, or that of
other parties concerned by or benefiting from the contract, may be
transferred outside the European Union if necessary for the
performance of your contract.
The sole purpose of such transfers is to allow the performance
of insurance and assistance claims, and only the data necessary for
the achievement of this purpose are transferred.
The recipients or categories of recipients authorized to receive
the data are the accredited staff of the medical administrators and
assistance companies as well as of the insurers, where
appropriate.
These transfers are made according to the regulations relating
to the protection of personal data applicable in the European
Union.
In accordance with the French data protection law n° 78-17 of
January 6 1978 as amended in 2004 and 2018 and to EU regulation
2016/679 of April 27th 2016, you have the right to Access, Rectify,
Erase, and to the Portability of, any data concerning yourself, as
well as the rights to the Restriction of and to Object to the
processing of your personal data, which you can pursue by writing
to our Data Protection Officer: [email protected] or by postal mail
to « ACS, To the attention of the DPO, 153, rue de l’Université,
75007 Paris, France » (together with a copy of an official ID).
You may send a complaint:
• On the CNIL website by filling out the online form.• By postal
mail writing to CNIL - 3 Place de Fontenoy - TSA 80715 - 75334
PARIS CEDEX 07 FRANCE
Regarding your health data, these rights may also be exercised
by writing to the ACS Medical Consultant (ACS, To the attention of
the Medical Consultant, 153, rue de l’Université, 75007 Paris,
France) together with of a copy of an official ID.
You may receive commercial offers from our company for products
or services similar to those you have requested. Should you wish to
receive commercial offers from our company, please check this
box:
A C S – I N SURANC E B ROK E RAGE
COMPANY 1 5 3 RU E D E L ’ UN I V E R S I
T E 7 5 0 0 7 P A R I S – F r a n c e
T E L + 3 3 ( 0 ) 1 4 0 4 7
9 1 0 0
Email : contact@acs‐ami.com Web site : www.acs‐ami.com
317 218 188 RCS Paris –S.A.S (Simplified joint‐stock company)
with a share capital of 150 000 € N° ORIAS 07 000 350 (www.orias.fr) In case of a complaint, please write to ACS Complaint Service at our postal address. ACS is controlled by the ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09 France
ACS
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A C S – I N S U R A N C E B R O K E R A G E C O M P A N Y 1 5 3
R U E D E L ’ U N I V E R S I T E 7 5 0 0 7 P A R I S – F r a n c e
T E L + 3 3 ( 0 ) 1 4 0 4 7 9 1 0 0 Email : [email protected] Web
site : www.acs-ami.com
317 218 188 RCS Paris –S.A.S (Simplified joint-stock company)
with a share capital of 150 000 € N° ORIAS 07 000 350
(www.orias.fr) In case of a complaint, please write to ACS
Complaint Service at our postal address. ACS is controlled by the
ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09
France
Medical questionnaire
INSTRUCTIONS: An answer is expected for each question. Any extra
information regarding the state of your health may be added in the
« Complementary information » section you will find after the
questionnaire.
Insured Last name : ___________________________________ First
name : ____________________________________ Date of birth :
____/____/________ Occupation : ______________________________
Email : _____________________________________ Height : _________ m
Weight : _________ kg
Spouse Last name : ___________________________________ First
name : ____________________________________ Date of birth :
____/____/________ Occupation : ______________________________
Email : _____________________________________ Height : _________ m
Weight : _________ kg
Children 1- First name : ____________________ Height : ______ m
Weight : ______ kg 3- First name : ____________________ Height :
______ m Weight : ______ kg2- First name : ____________________
Height : ______ m Weight : ______ kg 4- First name :
____________________ Height : ______ m Weight : ______ kg
Tobacco consumption Alcohol consumptionInsured Spouse Insured
Spouse
Do you smoke? Do you drink alcohol? Cigarettes/day Beer
(glasses/day) Cigars/day Wine (glasses/day) Pipes/day Spirits
(drinks/day)
Have you ever smoked? If yes, for how many years? (insured and
spouse) When did you stop and why? (insured and spouse)
Insured Spouse Child 1 Child 2 Child 3 Child 4 Note : if you
need more space for your answers, please use the "complementary
information" section you will find below. 1- Do you have or have
you ever had a congenital or hereditary disorder?
If YES, please indicate which disorder, onset date &
treatment:
2- Does your present state of health prevent you from performing
your full time occupation?
Therapeutic Part Time leave: Total leave of absence:
Reasons:
3- Have you undergone or been advised to undergo surgery, other
than for the extraction of the appendix, tonsils or adenoids?
Details of surgery? Dates(s) ?
4- During the last 5 years, have you had / do you have any
medical treatment (medication, acupuncture, physiotherapy, medical
appliances, psychotherapy…), excluding birth control ? Are you
currently undergoing diagnostic tests ?
Details :
5- During the past 5 years, have you been prescribed sick leave
or a medical treatment exceeding 3 weeks?
Please give reasons?
6- Have you received care or undergone tests during the past 5
years which have led to stay in a medical establishment (hospital,
clinic, convalescent home, physiotherapy, dietary needs or
treatment centre, sanatorium…)?
Date(s) ? (Please attach photocopies of post-operative and cell
reports)
7- During the last 24 months, have you had any symptoms for
which you did not consult a health professional and which should
have been treated ?
Details:
8- Over the next 6 months, is it planned for you to have any
medical examinations (laboratory tests, medical imaging,
endoscopy…) consult a specialist or undergo medical and/or surgical
treatment on an inpatient or outpatient basis ?
Details:
Yes No Yes No Yes No Yes No
Yes No Yes No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
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Yes
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4/6
ACS
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A C S – I N S U R A N C E B R O K E R A G E C O M P A N Y 1 5 3
R U E D E L ’ U N I V E R S I T E 7 5 0 0 7 P A R I S – F r a n c e
T E L + 3 3 ( 0 ) 1 4 0 4 7 9 1 0 0 Email : [email protected] Web
site : www.acs-ami.com
317 218 188 RCS Paris –S.A.S (Simplified joint-stock company)
with a share capital of 150 000 € N° ORIAS 07 000 350
(www.orias.fr) In case of a complaint, please write to ACS
Complaint Service at our postal address. ACS is controlled by the
ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09
France
Insured Spouse Child 1 Child 2 Child 3 Child 4 Note : if you
need more space for your answers, please use the "complementary
information" section you will find below. 9- During the past ten
years have youexperienced any of the following?
a) High blood pressure /hypertension, diabetes, cholesterol
problem, stroke, lung, heart or circulatory disease b)Respiratory
or allergic condition, emphysema, bronchitis, pneumonia, sleep
apnea, asthma c) Anxiety, headaches, drug or alcohol abuse,
neurological or psychological illness (including depression)d)
Gastritis, gastro-esophageal reflux, stomach or intestinal ulcers,
hernias, urinary tract or liver disorders (hepatitis, gallstones
and kidney stones, renal failure, lithiasis…), prostate,
thrombosise) Sciatica, herniated discs, lumbar pain, rheumatism
(including the vertebrae) arthritis, any skin condition such as
keratosis, melanoma...f) Any hormonal or glandular disease, blood
or immune system disease, cancer, leukemia or other blood related
illness g) For women only : have you in the past ten years had any
gynecological disorder ?h) Have you had any other medical
problemsnot mentioned on the questionnaire ?
If you answered YES to this question, please indicate which
illness and state clearly all relevant details (date, duration,
treatment, recovery date, after effects, comments). Please attach
photocopies of medical reports.
10- Do you plan to get hospitalized in the upcoming 12
months?
If YES, indicate the nature of the hospitalization:
11- Have you had a screening for the AIDS, hepatitis virus or
for one of the human Immuno-deficiency viruses?
If YES, please indicate the date, nature of the test and
result:
12- Have you had any after-effects resulting from an accident or
illness?
Details :
13- Do you suffer from a disability or are you entitled to a
disablement pension (civilian or military) or old age pension?
Nature of disability: Rate (please attach notification):
14- Are you currently covered by any medical or Life policy ?
Has any medical or Life insurance application been declined, rated,
restricted, or cancelled?
Complementary information
You can use the section below if, in the previous section, you
couldn't complete all the details regarding a medical condition.
Please do not forget to note the question number and the person
concerned. This will help us process your application promptly.
Question # _____ Person: ___________________________ Question #
_____ Person: ___________________________
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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Yes
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5/6
ACS
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A C S – I N S U R A N C E B R O K E R A G E C O M P A N Y 1 5 3
R U E D E L ’ U N I V E R S I T E 7 5 0 0 7 P A R I S – F r a n c e
T E L + 3 3 ( 0 ) 1 4 0 4 7 9 1 0 0 Email : [email protected] Web
site : www.acs-ami.com
317 218 188 RCS Paris –S.A.S (Simplified joint-stock company)
with a share capital of 150 000 € N° ORIAS 07 000 350
(www.orias.fr) In case of a complaint, please write to ACS
Complaint Service at our postal address. ACS is controlled by the
ACPR, 4 place de Budapest, CS 92459, 75436 Paris Cedex 09
France
Question # _____ Person: ___________________________ Question #
_____ Person: ___________________________
Question # _____ Person: ___________________________ Question #
_____ Person: ___________________________
Question # _____ Person: ___________________________ Question #
_____ Person: ___________________________
Question # _____ Person: ___________________________ Question #
_____ Person: ___________________________
I hereby declare that the above statements are full, complete
and true to the best of my knowledge and belief, and that I have
not declared or omitted to declare any particular that may mislead
the insurer. It is fully agreed that the penalties which apply in
the case of false statement, concealment or inaccuracy, are the
nullity of the contract or the reduction of the level of
coverage.
I agree that in the case of false or incomplete statement, the
insurer has the right to reduce the level of, or refuse,
coverage.
Signed in (town or city) _____________________ Date (DD/MM/YYYY)
__________________
Read and approved
____________________
Signature of the insured members aged 18 years old or more
6/6
ACS
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9110
1
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Standing order authorization
CREDIT CARD DEBIT AUTHORIZATION
I the undersigned, Mr, Mrs, Miss,
___________________________________ , holder of the below mentioned
credit card, authorize the establishment where is located my bank
account to proceed, if this situation permits, with the debits
requested for by the hereafter mentioned company. In case of
dispute, I can ask the establishment where is located my bank
account to suspend any debits on my card and I will settle the
dispute directly with the creditor company.
Name, first name and address of the card holder Creditor
company
Name and first name
_______________________________________________Address
_________________________________________________________________________________________________________________________ZIP
code City ________________________________________Country
_________________________________________________________
ACSSociété de Courtages d’Assurances
153, rue de l’Université75007 Paris - France
Account to be debited
Type of credit card : ☐ Visa ☐ Mastercard ☐ Eurocard ☐ AMEX
Number of the card to be debited Expiration date (month/year) /
Security code (3 digits on the back of the card)
Frequency of debit : ☐ annual ☐ half-yearly ☐ quarterly ☐
monthly
Date ________________________Signature of the card holder
Please fill out the form that corresponds to the payment method
of your choice.
For payments via standing order (valid only for holders of bank
accounts located in France), please completethe standing order
mandate you will find in the next page.
http://www.acs-ami.com/en
-
SEPA DIRECT DEBIT MANDATE
Mod
. 07.
00.0
0094
8 -
11/2
013
- M
AJ D
J : 1
1/20
13
Creditor's name and logo
By signing this mandate form, you authorise the creditor to send
instructions to your bank to debit your account, and you authorise
your bank to debit your account in accordance with the instructions
from the creditor. You are entitled to a refund from your bank
under the terms and conditions of your agreement with your bank. A
refund must be claimed within 8 (eight) weeks following the date on
which your account was debited
Unique Mandate Reference (UMR)
Debtor identification codeWrite any code number here which you
wish to have quoted by your bank
Party on whose behalf thepayment is made (if not the debtor)
In respect of the contract
Identification code of third-party debtor
Contract identification number Description of contract
Identification code of third-party creditor
Name of the third-party debtor: if your payment relates to an
arrangement between the creditor and a third party (for example if
you are paying a bill on behalf of another person), please writethe
other person's name here. If you are paying on your behalf leave
blank.
Please complete the fields marked *
Your name *
.....................................................................................................................................................................................................Debtor's
family name and given names
Your address *
.....................................................................................................................................................................................................Number
and road name
* ...................................
....................................................................................................
.........................................................Post code
Town/City Country
Your bank account *details International Bank Account Number -
IBAN
*Bank Identifier Code for your bank - BIC
Creditor's name *
.....................................................................................................................................................................................................Creditor's
name
SCI *SEPA Creditor Identifier (SCI)
*
.....................................................................................................................................................................................................Number
and road name
* ...................................
....................................................................................................
.........................................................Post code
Town/City Country
Type of payment * q Recurrent payment q Punctual payment
Signed at *
..........................................................................................................................................
Place Date (DD/MM/YYYY)
Signature(s) * Please sign here
Note: Your rights regarding the above mandate are explained in a
statement that you can obtain from your bank.
Details regarding the contract between the creditor and the
debtor -
For creditor's use only Please return to:
Maximum name lenght 70 characters
This line is a maximum of 35 characters long
Name of third-party creditor: the creditor must complete this
section if collecting payment on behalf of another party
The information contained in this transfer order, which must be
completed, must only be used by the creditor for the purpose of
managing therelationship with the customer. Customers may exercise
their right to access, rectify or refuse the processing of this
information provided forunder articles 38 and following of the
French data protection law, no. 78.17, dated 6 January 1978.
Assurances Courtages et Services
Ville_2: Pays_2: Name_1: POB_1: Nationality_1: case_1:
Offcase_2: Offcase_3: Offcase_4: Offcase_5: Offcase_6: Offcase_7:
Offcase_8: Offadresse_1: adresse_2: adresse_3: adresse_4: tel_1:
passeport_1: case_moi_seule: Offcase_moi_famille: Offcase_11:
Offcase_13: Offcase_15: Offcase_17: Offcase_19: Offcase_12:
Offcase_14: Offcase_16: Offcase_18: Offcase_20: OffName_5: DOB
DDMMYYYY_2: Name_6: DOB DDMMYYYY_3: Name_7: DOB DDMMYYYY_4: Name_8:
DOB DDMMYYYY_5: cotisation annuelle 1: case_21: Offcase_24:
OffCotisation annuelle assistance: case_37: Offcase_38: Offcase_39:
Offcase_40: OffCotisation annuelle responsabilite: income_1:
case_41: Offcase_42: Offcase_43: OffCotisation annuelle 3: case_44:
Offcase_45: Offformula_1: formula_2: case_145: Offcase_146:
Offcase_147: OffCotisation invalidité: case_148: Offcase_149:
OfftotalCotisation: 0date adhésion: case_245: Offcase_247:
Offcase_248: Offcase_246: Offcase_345: Offcase_344: Offcase_346:
Offcase_347: Offacompte: case_444: Offcase_445: Offcase_446:
Offcase_447: OffA_100: DOB DDMMYYYY_1000: Références de
lIntermédiaire: Je soussignée M Mme Mle: Nom et Prénom: Adresse 1:
Adresse 2: codePostal: Ville: Pays: typeCarte: Offcb1: cb2: cb3:
cb4: moisCb: anneeCb: nsecu: periodPrev: OffUnique Mandate
Reference (UMR): Debtor's family name and given names: Number and
road name_1: Post code_1: City_1: Country_1: International Bank
Account Number - IBAN: Bank Identifier Code for your bank – BIC:
Creditor's name: ASSURANCES COURTAGES ET SERVICESSEPA Creditor
identifier (SCI): FR 44 ZZZ 494888 Number and road name_2: 153 RUE
DE L'UNIVERSITEPost code_2: 75007City_2: PARISCountry_2: FRANCECase
1: OuiCase 2: OffSigned at: Debtor identification code: Third party
debtor: Identification code of third party debtor: Name of third
party creditor: Identification code of third party creditor: In
respect of the contract: EXPATRIATE CONTRACTContract identification
number: Please return to: ASSURANCES COURTAGES ET SERVICES153 RUE
DE L'UNIVERSITE 75007 PARIScase_28: Offcase_281: Offoffres-comm:
OffDate: le: Profession_Assuré: Taille_Assuré: Poids_Assuré:
Profession_Conjoint: Email_Conjoint: Taille_Conjoint:
Poids_Conjoint: Enfant1_Taille: Enfant1_Poids_3: Enfant2_Taille:
Enfant2_Poids: Enfant3_Taille: Enfant3_Poids: Enfant4_Taille:
Enfant4_Poids: Fumez_vous_assuré: Offcigarettes_assuré: [
]cigares_assuré: [ ]pipes_assuré: [ ]cigarettes_conjoint: [
]cigares_conjoint: [ ]pipes_conjoint: [ ]Fumez_vous_conjoint:
Offbière_assuré: [ ]vin_assuré: [ ]spirit_assuré: [
]bière_conjoint: [ ]vin_conjoint: [ ]spirit_conjoint: [
]alcool_assuré: Offalcool_conjoint: OffSi oui combien de temps
avezvous fumé assuré principal et conjoint: Depuis quand avezvous
arrêté de fumer et pourquoi assuré principal et conjoint:
ExFumeur_Assuré: OffExFumeur_Conjoint: OffQM1_A: OffQM1_C:
OffQM1_E1: OffQM1_E2: OffQM1_E3: OffQM1_info_1: QM1_E4: OffQM2_A:
OffQM2_C: OffQM2_E1: OffQM2_E2: OffQM2_E3: OffQM2_E4:
OffQM2_info_1: QM2_info_2: QM2_info_3: QM3_info_1: QM3_E4:
OffQM3_E3: OffQM3_E2: OffQM3_E1: OffQM3_C: OffQM3_A: OffQM4_A:
OffQM4_C: OffQM4_E1: OffQM4_E2: OffQM4_E3: OffQM4_info_1: QM4_E4:
OffQM5_A: OffQM5_C: OffQM5_E1: OffQM5_E2: OffQM5_E3: OffQM5_info_1:
QM5_E4: OffQM6_A: OffQM6_C: OffQM6_E1: OffQM6_E2: OffQM6_E3:
OffQM6_info_1: QM6_E4: OffQM7_A: OffQM7_C: OffQM7_E1: OffQM7_E2:
OffQM7_E3: OffQM7_info_1: QM7_E4: OffQM8_A: OffQM8_C: OffQM8_E1:
OffQM8_E2: OffQM8_E3: OffQM8_E4: OffQM8_info_1: QM9_info_1: QM9_A:
OffQM9_C: OffQM9_E1: OffQM9_E2: OffQM9_E3: OffQM9_E4:
OffQM10_info_1: QM10_A: OffQM10_C: OffQM10_E1: OffQM10_E2:
OffQM10_E3: OffQM10_E4: OffQM11_info_1: QM11_A: OffQM11_C:
OffQM11_E1: OffQM11_E2: OffQM11_E3: OffQM11_E4: OffQM12_info_1:
QM12_A: OffQM12_C: OffQM12_E1: OffQM12_E2: OffQM12_E3: OffQM12_E4:
OffQM13_info_2: QM13_info_1: QM13_A: OffQM13_C: OffQM13_E1:
OffQM13_E2: OffQM13_E3: OffQM13_E4: OffQM14_info_1: QM14_A:
OffQM14_C: OffQM14_E1: OffQM14_E2: OffQM14_E3: OffQM14_E4:
OffInfos_Sup_Question_1: Infos_Sup_Personne_1: Infos_Sup_Contenu_1:
Infos_Sup_Question_2: Infos_Sup_Personne_2: Infos_Sup_Contenu_2:
Infos_Sup_Question_3: Infos_Sup_Personne_3: Infos_Sup_Contenu_3:
Infos_Sup_Question_4: Infos_Sup_Personne_4: Infos_Sup_Contenu_4:
Infos_Sup_Question_5: Infos_Sup_Personne_5: Infos_Sup_Contenu_5:
Infos_Sup_Question_6: Infos_Sup_Personne_6: Infos_Sup_Contenu_6:
Infos_Sup_Question_7: Infos_Sup_Personne_7: Infos_Sup_Contenu_7:
Infos_Sup_Question_8: Infos_Sup_Personne_8: Infos_Sup_Contenu_8:
Infos_Sup_Question_9: Infos_Sup_Personne_9: Infos_Sup_Contenu_9:
Infos_Sup_Question_10: Infos_Sup_Personne_10: Infos_Sup_Contenu_10:
QM_Fait_à: Date_QM: Nom_Assuré: Prénom_Assuré: Date de
naissance_Assuré: Email_Assuré: Nom_Conjoint: Prénom_Conjoint: Date
de naissance_Conjoint: Enfant1_Prénom: Enfant2_Prénom:
Enfant3_Prénom: Enfant4_Prénom: