Acceptance Questionnaire

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Dossiernummer
Acceptance Questionnaire Nationale Nederlanden
To ask the right questions, we would like to know if:
You want to apply for a home insurance and/or contents insurance or currently have this insurance at Nationale Nederlanden?*
- Yes
- No
You want to apply for a legal assistance insurance or currently have this insurance at Nationale Nederlanden?*
- Yes
- No
You want to apply for a car and/or motorcycle insurance or currently have this insurance at Nationale Nederlanden?*
- Yes
- No
Does it concern?*
- One car
- Two cars
- One motorcycle
- Two motorcycles

Personal situation
Did you or one of the persons you want to co-insure, such as family members, housemates or your partner;
commit a violation in the last 8 years that caused you to be in contact with the police and/or convicted by the judiciary?*
- Yes
- No
Answer this question with "yes" if there has been:
- Theft, fraud, scams, forgery, or an attempt to do so;
- Destruction, damage, assault, extortion, or a crime against the freedom or life of an individual or an attempt to do so;
- Violation of the Weapons and Ammunition Act, the Opium Act or the Economic Offenses Act (Dutch: Wet wapens en munitie, de Opiumwet of de Wet economische delicten);
- Insurance fraud or deliberate deception of a financial institution;
Elaboration of a maximum of 1024 characters:*
have a (conditional) rejection of your driving permittance in the last 8 years? (Dutch: de laatste 8 jaar een (voorwaardelijke) ontzegging van de rijbevoegdheid gehad?)*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
receive a refusal or cancellation from an insurer in the last 5 years?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
in the last 5 years suffer damage or caused damage by an event covered by the insurance(s) you apply for?*
- Yes
- No
How many claims/damages have you had in the last 5 years?*
When was the last claim/damage?*

About the driver and the car
Who is the driver of the car?*
Do you have a driving license which is valid in the Netherlands?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Is your driving ability influenced by a disability, illness or medication?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Do you have any remarks (Dutch: aantekeningen) on your driver's license?*
- Yes
- No
You usually receive a remark on the driver's license if additional conditions or restrictions are imposed where under you are allowed to drive a motor vehicle.
Elaboration of a maximum of 1024 characters:*
Has the vehicle been uninsured for more than 14 days?*
- Yes
- Nee
If at present there is an uninsured period of longer than 14 days, answer the question with yes. As soon as the license plate is officially registered, an insurance obligation applies. Car owners who have not taken out insurance risk a fine from the RDW. In addition, you are not insured for any damage. The period and reason for not being insured will be taken into account in the assessment of your application.
Elaboration of a maximum of 1024 characters:*
How can the number of claim-free years be demonstrated?*

About the driver and the second car
Who is the driver of the second car?*
Do you have a driving license which is valid in the Netherlands?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Is your driving ability influenced by a disability, illness or medication?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Do you have any remarks (Dutch: aantekeningen) on your driver's license?*
- Yes
- No
You usually receive a remark on the driver's license if additional conditions or restrictions are imposed where under you are allowed to drive a motor vehicle.
Elaboration of a maximum of 1024 characters:*
Has the vehicle been uninsured for more than 14 days?*
- Yes
- No
If at present there is an uninsured period of longer than 14 days, answer the question with yes. As soon as the license plate is officially registered, an insurance obligation applies. Car owners who have not taken out insurance risk a fine from the RDW. In addition, people are not insured for any damage. The period and reason for not being insured will be taken into account in the assessment of your application.
Elaboration of a maximum of 1024 characters:*
How can the number of claim-free years be demonstrated?*

About the driver and the motorcycle
Who is the driver of the motorcycle?*
Do you have a motorcycle driving license which is valid in the Netherlands?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Is your driving ability influenced by a disability, illness or medication?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Do you have any remarks (Dutch: aantekeningen) on your driver's license?*
- Yes
- No
You usually receive a remark on the driver's license if additional conditions or restrictions are imposed where under you are allowed to drive a motor vehicle.
Elaboration of a maximum of 1024 characters:*
Has the vehicle been uninsured for more than 14 days?*
- Yes
- No
If at present there is an uninsured period of longer than 14 days, answer the question with yes. As soon as the license plate is officially registered, an insurance obligation applies. Car owners who have not taken out insurance risk a fine from the RDW. In addition, people are not insured for any damage. The period and reason for not being insured will be taken into account in the assessment of your application.
Elaboration of a maximum of 1024 characters:*
How can the number of claim-free years be demonstrated?*

About the driver and the second motorcycle
Who is the driver of the second motorcycle?*
Do you have a motorcycle driving license which is valid in the Netherlands?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Is your driving ability influenced by a disability, illness or medication?*
- Yes
- No
Elaboration of a maximum of 1024 characters:*
Do you have any remarks (Dutch: aantekeningen) on your driver's license?*
- Yes
- No
You usually receive a remark on the driver's license if additional conditions or restrictions are imposed where under you are allowed to drive a motor vehicle.
Elaboration of a maximum of 1024 characters:*
Has the vehicle been uninsured for more than 14 days?*
- Yes
- No
If at present there is an uninsured period of longer than 14 days, answer the question with yes. As soon as the license plate is officially registered, an insurance obligation applies. Car owners who have not taken out insurance risk a fine from the RDW. In addition, people are not insured for any damage. The period and reason for not being insured will be taken into account in the assessment of your application.
Elaboration of a maximum of 1024 characters:*
How can the number of claim-free years be demonstrated?*

Legal assistance
Applies to you or one of the persons you want to co-insure, such as your partner, family members or housemates, that:
one of you has been involved in a legal dispute in the past 5 years?*
- Yes
- No
Pay attention! There is no coverage for conflicts that already exist or have arisen before the effective date of this insurance policy!
This also applies if the policyholder or one of the persons to be co-insured expects or may expect to be involved in a dispute.
How often has one of the aforementioned co-insured persons been involved in a legal dispute?*
What did this relate to?*
Elaboration of a maximum of 1024 characters:*
one of you is expected to become involved in a dispute or legal problem in the foreseeable future and / or to have to use a legal service provider?*
- Yes
- No
What does this relate to?*
Elaboration of a maximum of 1024 characters:*
one of you currently receives a benefit from a social insurance or disability insurance such as a WAO, WIA, ZW or AOV?*
- Yes
- No
Do you, or one of the persons you want to co-insure, receive a benefit or provision on the basis of social insurance or disability insurance when you want to apply for this insurance?
Then the coverage does not apply to events that take place within two years after you have taken out the Work & Income coverage.
Examples of benefits or provisions are:

- the Disability Insurance Act (WAO)
- the Work and Income according to Labor Capacity Act (WIA)
- the Sickness Benefits Act (ZW)
- individual occupational disability insurance
Elaboration of a maximum of 1024 characters:*

From which account number do you want to pay the premium?*
Agreement on digital policy, taking note of conditions and final statement:*
- I agree that I will receive the policy digitally and I prefer to receive other documents digitally as much as possible
- I agree with the applicable policy conditions, privacy statement and the applicable insurance card(s)
- I declare that the information on which the insurance quotation is based is correct and complete. I will send corrected information with this application if necessary. I also declare that the answers given above are correct and complete. I declare that I want to conclude the insurance contract(s) with Nationale-Nederlanden Schadeverzekering Maatschappij N.V.. I agree with the application of the general terms and conditions to the requested insurance policy(s).
You are obliged to agree to all these conditions if you want to take out the insurance.
Thank you for filling in the acceptance questionnaire!

Click on send at the bottom of the page to complete the questionnaire, then we will initiate the application with the insurer.

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Acceptance Questionnaire

Acceptance Questionnaire Nationale Nederlanden