Request for a quote for Extended LAA/UVG insurance

Please fill in the following form to send us your details. We will then send you the documents required to take out extended LAA/UVG insurance.

Title

Name *

First name *

Address *

Postcode and town *

Telephone number *

Email address *

Date of birth (dd.mm.yyyy) *

Client No. (if already affiliated to Groupe Mutuel)

Social security No.

Details of the last employer

Company name *

Address *

Telephone *

Contract No.

Do you have non-occupational accident insurance with this employer (employed at least 8 hours a week)? *

Yes

Last day of entitlement to salary (Usually, this is the last day of work) *

Beginning of extended insurance *

Would you like to pay the premium monthly? (If you select "No", the total amount will be charged.) *

Yes

Comment

You will remain covered by the accident insurance of your former employer until the 31st day after the end of the entitlement to your salary. Therefore, extended insurance starts on the 32nd day after the last salary has been paid. Please note that daily allowance benefits under accident insurance, that replace the obligation to pay a salary if the worker is prevented from working, are also considered as a salary.

Example of calculation:
Last day of work: 28.02.2015
LAA/UVG coverage until 31.03.2015
Beginning of extended insurance: 01/04/2015

End of extended insurance (max. 6 months) *

Message

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