Claim-Free Years Transfer

Claim-Free Years Transfer
This form allows you to request a transfer of Claim-Free Years. It must be completed and signed by the person or representative of the entity giving the Claim-Free Years.

Before proceeding, please ensure that the previous insurer has confirmed in Roy-data the Claim-Free Years concerned, as we need to verify their number in the database.

Claim-Free Years can only be used for one insurance policy at a time.
Qover contract reference*
Email, as used in the Qover contract*
example@example.com
I transfer the Claim-Free Years as*

(Ex)Partner(Grand)ParentRepresentative of my sole proprietorship
As (ex)partner, I request a transfer of Claim-Free Years due to*

DeceaseDivorce or dissolution, with transfer of 50% claim-free yearsDivorce or dissolution, with transfer of 100% claim-free years
As "representative of my sole proprietorship", I want to transfer the Claim-Free Years*

from my private name to my sole proprietorshipfrom my sole proprietorship to my private name
My details (of the person giving the Claim-Free Years)
Details of the deceased person
Details of my sole proprietorship
Full name*

First NameLast Name
Name of sole proprietorship*
Birthdate*

MonthDayYear
VAT number
Full address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I declare that I am the person authorizing the transfer of my Claim-Free Years and that I understand that I can no longer use them for another insurance policy.
I declare that I am the representative of the above-named company and that I am hereby authorised to sign on its behalf
Sign here*

Clear
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