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Please fill out the form below and one of our representatives will be in touch with you in the near future - Time 20 s / Veuillez completer le formulaire ci-dessous et l’un de nos experts prendra attache avec vous dans les plus brefs délais . Temps 20 s
Group (Full name) /Organisation (Nom complet)
Contact person at the company / Interlocuteur entreprise
Job Title / Fonction
International phone number /téléphone international
Phone
What's App (optional)
Email address/ adresse courriel
Company address/ adresse de l’entreprise (optional)
Country Head office/Pays du siege social (optional)
- Select -
Australia
Canada
India
United Kingdom
United States
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, DR of
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Federated States of Micronesia
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Islands and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao Peoples Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
North Korea
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
UAE-Abu Dhabi
UAE-Ajman
UAE-Dubai
UAE-Fujairah
UAE-Ras al-Khaimah
UAE-Sharjah
UAE-Umm al-Quwain
Uganda
Ukraine
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands (British)
Virgin Islands (US)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Contract start date/Date de départ de l’assurance (optional)
Current group renewal date/ date de renouvellement de la police actuelle (optional)
Write a label for No of Employees / VEUILLEZ INDIQUER LE NOMBRE D’EMPLOYÉS (optional)
- None -
3-50
5-100
100-200
200-300
Large Group
Number of dependent/ Nombre d’ayants droits ? (optional)
DO YOU NEED IN-PATIENT BENEFITS INCLUDING ASSISTANCE / BESOIN D'UNE COUVERTURE HOSPITALISATION INCLUANT L'ASSISTANCE ? (optional)
Yes
No
DO YOU NEED OUT-PATIENT BENEFITS / BESOIN DE MÉDECINE COURANTE ? (optional)
Yes
No
DO YOU NEED A CO-INSURANCE / BESOIN D'UNE FRANCHISE? (optional)
Yes
No
PERCENTAGE MAXIMUM CO-INSURANCE/DEDUCTIBLE/POURCENTAGE FRANCHISE/DEDUCTIBLE? (optional)
DO YOU NEED PREVENTIVE CARE/MEDICAL CHECK-UP/BESOIN DE PREVENTION/BILAN DE SANTE ? (optional)
Yes
No
DO YOU NEED MATERNITY CARE / BESOIN D'UNE COUVERTURE MATERNITÉ ? (optional)
Yes
No
DO YOU NEED DENTAL & VISION CARE / BESOIN DE DENTAIRE ET D'OPTIQUE ? (optional)
Yes
No
DO YOU NEED LIFE & PROTECTION INCOME INSURANCE / AVEZ-VOUS BESOIN DE PREVOYANCE? (optional)
Yes
No
HOW DID YOU HEAR ABOUT AOC INSURANCE BROKER / COMMENT CONNAISSEZ-VOUS AOC INSURANCE BROKER ? (optional)
- None -
Social Media
AOC Website
Google Search Engine
Referral / Recommandation
Other / Autres
REMARKS/REMARQUES (optional)
Terms
I AGREE & CONSENT
AOC INSURANCE BROKER PRIVACY STATEMENT
/ JE CONSENS ET J'ACCEPTE LA
DÉCLARATION DE CONFIDENTIALITÉ D'AOC INSURANCE BROKER