Application Form

Yes, I would like to subscribe to the Youth Protection Plan immediately.

I acknowledge to have taken notice of the attached Terms and Conditions

Yes, I agree with the immediate effect of my insurance policy upon acceptation of my filled in application form with AIG Europe Limited

My choice :

Youth Protection Plan. I agree to pay € 105 (all taxes included) per year per child. Your policy will be sent to your home address within the next couple of days

Data Protection By signing this application, you agree that AIG Europe Limited may keep information about you and your policy. The information you have given above will be used to process your application, administer your policy or any claim you may make and to carry out research, analysis and profiling. AIG Direct will not disclose any information relating to your state of health or claims to a third party (according to the law of December 8th 1992). AIG Europe will not pass your name to any third party for marketing purposes, but may wish to contact you by post, telephone or email with news of their own products. If you do not wish to receive offers , you should inform us in writing (on the following address – AIG Europe Limited – Pleinlaan 11 – 1050) indicating his/her name, surname, address and if possible the customer reference. You may ask for details of the information we hold about you and, where necessary, correct the information.

* Title	Mr Mrs
* Last Name	Invalid characters
* First Name	Invalid characters
* Date of Birth (DD/MM/YYYY)	Incorrect date format
* Street / house number	Invalid characters
	Invalid characters
* Postal code	Invalid characters
* City	Invalid characters
Telephone number	Invalid characters
I am a member of Afiliatys

Name of the child	Invalid characters
Surname of the child	Invalid characters
Date of Birth of the child (DD/MM/YYYY)	Incorrect date format
Gender	M F

AIG Europe Limited (AEL) is undertaking a restructure as part of its plans for the UK leaving the European Union and intends to transfer its European business to AIG Europe S.A. (AIG Europe) which is expected to take effect on 1 December 2018. AIG Europe is a member of the same group of companies as AEL. As a result of the restructure, your policy will transfer to AIG Europe but this will have no effect on the cover provided under the policy. Please visit www.aig.com/Brexit to view information relating to the proposed transfer and the rights you have.

Vanbreda International NV has developed this offer in exclusive cooperation with the insurance company AIG Europe Limited - Belgisch Bijkantoor / Succursale Belge - Pleinlaan 11 / Boulevard de la Plaine 11 – B – 1050 Brussel / Bruxelles Tel +32 2 739 90 00 - Fax +32 2 739 91 02 www.aig.be AIG Europe Limited - Vennootschap naar Engels recht / Société de droit anglais Maatschappelijke zetel / Siège social : The AIG Building, 58 Fenchurch Street, London EC3M 4AB, United Kingdom – n° 01486260 RPM / RPR Bru BTW / TVA 0847.622.919 - Citibank 570-1210370-62 – IBAN : BE51 5701 2103 7062 – BIC : CITIBEBX Veuillez trouver notre Privacy Policy sur www.aig.be/be-privacy-policy - U vindt onze Privacy Policy op www.aig.be/be-privacy-policy
Vanbreda International NV established at Plantin en Moretuslei 299, 2140 Antwerp is part of Vanbreda, an independent group of financial service providers and consultants. Vanbreda International N.V. registered at the Commission for banks, finances, and insurances being (CBFA) under the code 13718.

Your contract has been insured with AIG Europe Limited within the framework of an exclusive cooperation with Vanbreda International N.V. . Given the fact that the products can not be adapted to the needs of each individual insured person we recommend to read the Terms and Conditions in appendix attentively before subscribing to the insurance contract.