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In accordance with the European directive MiFID we are required by Belgian legislation to register all pre-contractual actions, to document personal details and keep these available for review by the appointed authority FSMA. This means we are obliged to ask you to complete the below form completely and correctly before we can offer you a quote or personal advice.

Current Person to be insured
Purpose of your stay abroad
Your contact details

Mrs

Company

University

Other

Name (as in passport) or Organisation Name

First Name (as in passport) or Contact Person

If you already have a policy with Expat & Co please enter your policy number here

Date of Birth

Destination Country

Should you be visiting multiple countries, please give details in the comment box below.

Country of origin

If multiple persons are to be insured, please give their surnames, first names and dates of birth as well as their destination country, country of social security and country of origin. If the list is too long to enter below you may send a description of the group, along with an excel list or word document with the details of the persons to be insured by separate email to info@expatinsurance.eu, referencing this application (for example, add your own reference below and quote this in your email).

Estimated leaving date (dd/mm/yyyy):

Estimated date of return (dd/mm/yyyy):

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