Form "information request" - RSR-lijst autoverzekeringen

Street + number of the insurance subscriber:

Please enter your full adress

ZIP code + city of the insurance subscriber:

Please enter your ZIP code and city

Is the insurance taker also the main driver:

Yes

No

Please select

Street + number of the main driver:

Please enter your adress

ZIP code + city of the main driver:

Gelieve een postcode en plaatsnaam in te geven

Car brand:

Please enter the brand of your car

Model:

Please enter the model of your car

Vehicle Identification Number:

Please enter the Vehicle Identification Number

Date of first registration:

Selecteer een datum

Please select the date of first registration

kW car:

Please enter the car power in kilowatts

Number of seats:

Please enter the number of seats

Where did you subscribe your most recent car insurance?

Please enter an insurance company name

Number of at-fault accidents:

Please enter the number of at-fault accidents

Aggravating circumstances and other information (such as license suspension, non-payment of premium ...):

Please enter detailed information.

Please complete the information for your application