Please enable JavaScript in your browser to complete this form. - Step 1 of 4APPLICANT DETAILSName *Surname *Date of birth *ProfessionPhoneEmail *Do you wish to insure your spouse?YESName of Spouse *Spouse's Surname *Date of Birth of Spouse *Occupation of SpouseNextBASIC COVERAGESelect Type of Basic Coverage *Death by AccidentAccidental Death, Permanent Total or Partial Disability from AccidentDesired lump sum (€) *50,000100,000200,000300,000400,000500,000600,000700,000800,000900,0001,000,000PreviousNextADDITIONAL COVERAGEMonthly income compensationSelect Waiting PeriodWaiting Period 7 days - From Accident and/or IllnessWaiting Period 7 days - Illness OnlyWaiting Period 14 days - From Accident and/or IllnessWaiting Period 14 days - Illness OnlyWaiting Period 30 days - From Accident and/or IllnessWaiting Period 30 days - Illness OnlyWaiting Period 7 days - Accident OnlyNo Waiting Period - By Accident onlyMonthly Income Protection Amount (€) *Do you suffer from any illness or are you taking prescription medication for any medical problem? *YESNODescription of Medical Problem *PreviousNextCOMMUNICATIONChoose a communication method *PhoneE-mailWhat is the best time to contact you? *How did you hear about AIC Insurances? *Google SearchFacebookFrom a friend/acquaintanceEmail campaignOtherTerms and Conditions *I agree to the terms and conditionsWe will provide you with an insurance quote based on the information you have provided us. It is essential that all information and responses you enter are true and accurate, and all relevant information requested must be stated. Failure to provide accurate information and failure to declare all relevant data may result in the cancellation of your insurance and non-payment of claims.AIC Antigonos Insurances follows the principles of the GDPR (limitation of purpose, minimization of data, accuracy, limitation of storage period). The protection and security of your personal data is a matter of utmost importance to us. We are committed to always following these principles and advising you on how you prefer us to communicate with you.PreviousSubmission
