ERICON broker - Personal Information Form

Using our online form to transmit your personal details, not only are you doing this in an utmost secure manner (SSL) - verified by 'Let's Encrypt' - but also only sending us the information required to complete your request.

This saves valuable time for all involved, allowing you to focus on the more important things in life.

Step 1 of 2 - About yourself

Personal Details

Title *

Firstname(s) *

Surname(s) *

Date of Birth *

Nationality *

Street, No. *

Postcode *

Town *

Country

Personal Status *

Do you have children

Yes

No

Employment Status *

Occupation & Industry

If self-employed / Freelance, please provide full details

Communications

Email *

Telephone

Microsoft Teams

Add your Teams name for easier and quicker consultations!

Banking Information

Bank Institute

Name of bank

IBAN

German IBAN is always 22 digits (e.g. DE91 1000 0000 0123 4567 89)

Account Holder

Only if different to policy holder!

Credit Card Information

Type of Card

Card Number

Start Date

Expiry Date