ERICON broker - Application Data Form

Using our online form to transmit your personal details allowing us to complete your application for international health insurance,
not only are you doing this in an utmost secure manner (SSL) - verified by 'Let's Encrypt' - but also sending us just the information required.
This saves valuable time for all involved, allowing you to focus on the more important things in life.
THANK YOU!

Step 1 of 3 - About yourself

Personal Details

Title *

Firstname(s) *

Surname(s) *

Date of Birth *

Nationality *

Street, No. *

Postcode *

Town *

Country

Marital Status *

Occupation

Employment Status *

Profession *

Please provide full details

Industry

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!