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ACCIDENT INSURANCE FORM
Dear Client,
Thank you, that You are interested in VIKO DRAUDA services. With this questionnaire assistance we will be able to prepare people accident insurance options.
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* Indicates required question
Email
*
Your email
I agree that the company will process my personal data.
*
Yes
No
Insurer's name and surname
*
Your answer
Insurer's address
*
Your answer
The desired start of the validity (insurance is valid for 12 months)
*
MM
/
DD
/
YYYY
Insurance area?
*
Lietuva/ Lithuania
Visas pasaulis (išskyrus Rusija ir Baltarurija) / The whole world (apart Russia and Belarus)
Insured people name and surname? (Enter if the insured is not only policyholder).
Your answer
Who's going to be beneficiary?
*
Insurer
Other:
Does the insured person work in a dangerous job? (NOTE: If the insured works dangerous job, the insurance price will be increased three times)
*
Yes
No
Select insurance option.
*
Minimum
Standart
Maximum
Select validity time
*
Working hours only, 8h
24/7
24/7 + During sports
Are there any comments you would like to add?
Your answer
Send me a copy of my responses.
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