Als startup is het belangrijk om goed verzekerd te zijn. Met onderstaande simpele stappen vraagt u via Simtra bij meerdere verzekeraars kosteloos een offerte aan voor verschillende verzekeringen die relevant zijn voor startups.

Application form

Company information

Name of Applicant *

Trading Name (if different) *

Corporate Address *

Postal code *

Mailing Address *

Postcode *

Chamber of commerce number (KvK) *

Locations (if other than the above) *

All Named Insureds

(Please explain relationship)

Please describe your Insured activities, per insured entity (hoedanigheid) *

Requested Coverage and sum insured

Public Liability € *

Pure Financial Loss € *

Please provide the following information for the past, current and future financial years:

Employees (number) *

Vul onderstaand de verhouding van uw medewerkers in:

Clerical / Managerial staff not involved in manual work % *

Sales and Marketing % *

Laboratory Workers % *

Manual Workers % *

Other (please describe) % *

Total Estimated Wage roll € *

Was a Risk Inventarisation and Evaluation (RI&E) survey performed? If yes, please attach report. *

Do any of the applicant’s employees provide direct patient care? *

Ja
Nee

Do they carry their own individual medical professional liability coverage? *

Ja
Nee

Does the applicant operate an inpatient facility? *

Ja
Nee

Does the applicant or its employees have a financial interest in the products of the applicants clients? *

Ja
Nee

Sponsored Clinical Trials (or planned/projected) *

Product *

Number of New Subjects over the Next Policy Period *

Indications *

Country *

Please attach approved protocols and informed consent documents for active clinical trials. *

List new products expected to be introduced. *

List any discontinued products. (please indicate reason(s) *

This Proposal Form and all materials submitted with it will be held in confidence. For further information about CNA's policies and practices with

regard to the privacy and confidentiality of information provided by you to us, please see our Privacy Statement at www.cnaeurope.com or contact our Company Secretary at the address listed below. Completing and signing this Proposal form does not bind coverage.

Coverage will not be bound, nor will a policy be issued until the applicant signifies acceptance of the Company's premium quotation.

Historic loss

Policy Period *

Insurer *

Number of Claims *

Total Incurred *

Nieuw veld *

Have any known occurrence(s) not yet been reported? *

Ja
Nee

Please enclose any documents, lists or explanations, as required, in response to various questions throughout the body if this insurance Proposal. In addition, please provide copies of the following: Marketing or advertising brochures or descriptive mater *

Signature in Full *

Name (Please print.) *

Position in Company (Please print.) *

Email *

Date *

Declaration

I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of Insurance, I/we undertake to inform Underwriters.

All questions must be answered and the application must be signed and dated.

Stuur mij een kopie

Naam organisatie *

KvK nummer *

Verwachte startdatum onderzoek *

Verwachte einddatum onderzoek *

E-mailadres contactpersoon *

Upload uw (concept) protocol *

Upload aantal deelnemers per land *

Lengte inclusieperiode *

Upload (concept) toestemmingsverklaring

Aanvullende relevante informatie

Naam organisatie *

KvK nummer *

Naam contactpersoon *

E-mailadres contactpersoon *

Telefoonnummer contactpersoon *

Omschrijving van uw startup

Welke verzekeringen bent u naar op zoek?

Aanvullende relevante informatie

Stuur mij een kopie

Application form | startups

Application form

Op zoek naar de juiste verzekeringen?

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