LAST NAME: FIRST NAME: EMAIL: TELEPHONE: BIRTH DATE:    JJ/MM/AAAA
SEX:     MAN WOMAN SMOKER: YES NO
YOUR CURRENT EMPLOYMENT: YOUR ANNUAL SALARY:
SINCE MORE ONE YEAR ?     YES NO AUTONOMOUS WORKER ? YES NO     PRODUCT: 30 DAYS 60 DAYS 90 DAYS 115 DAYS
DESIRED AMOUNT INSURANCE:
HAVE YOU QUESTIONS (OPTIONAL):