EN
•
FR
•
NL
*
Page Content
Contact our services
1
Your question
2
Confirm
Contact our services
Do you have questions about your contract or the succession of your file? Please fill out this form. We ensure that you will receive a personal response as quickly as possible.
Your demand
Briefly describe your question *
With this information we are able to give you a personalized answer.
Your message may not contain the following characters: <,>, /
Do you want to add attachments (benefit statements, hospital bills)?
Your data
Name*
With this information we are able to give you a personalized answer.
Your message may not contain the following characters: <,>, /
First name*
With this information we are able to give you a personalized answer.
Your message may not contain the following characters: <,>, /
Salutation*
Mr
Mrs
Miss
Birthdate*
With this information we are able to give you a personalized answer.
Address
Street
Number
Box
Postal code
Location
Your message may not contain the following characters: <,>, /
Could you enter a correct number?
Could you enter a correct postal code?
Your message may not contain the following characters: <,>, /
Email address*
With this information we are able to give you a personalized answer.
Could you enter a correct email address?
Telephone number
With this information we are able to give you a personalized answer.
Could you enter a correct telephone number?
* Mandatory fields
By clicking "Next", I agree to allow AG Insurance to use my personal data to contact me regarding my request. My personal data won't be communicated to third parties. My data will be processed in accordance with the applicable data protection and privacy laws as well as with AG Insurance's Privacy Notice and Cookie Policy. I hereby acknowledge that I have read
AG Insurance's Privacy Notice
and
Cookie Policy
.
Next