Finalize your application in just a few minutes

To complete the setup of your coverage, we need to collect certain mandatory information as part of our advisory duty.

This questionnaire allows us to better understand your situation, tailor the coverage to your needs, and ensure that your subscription complies with regulatory requirements (DDA / ACPR).

Practical information

⏱️ Duration: approximately 3 to 5 minutes
🔒 Your information is strictly confidential and used solely for the purpose of supporting you

We invite you to complete this form carefully in order to finalize your application under the best possible conditions.

Please fill in the information below:

Ambrelia
We cover Anyone, Anywhere
Duty of Advice Form
Hospi Safe & Life Safe Contracts — Allianz
✓ DDA / ACPR Compliant
1 Distributor Identity
Name: Kevin Elbaz  ·  Company: Ambrelia
Status: Insurance Broker — Allianz Authorised Agent
ORIAS No.: 11 064 575
Email: kevin.elbaz@ambrelia.com
Remuneration: Commission on premium paid by Allianz
Conflict of interest: As Allianz agent, the broker represents the insurer for these specific contracts.
2 Client Information
Required field
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Valid email required
3 Needs Analysis DDA Art. L.521-4
Required field
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4 Contract(s) subscribed *
🏥
Hospi Safe
Allianz · Hospitalisation
🛡️
Life Safe
Allianz · Life / Death cover
ℹ️ Combined subscription Hospi Safe + Life Safe. The client acknowledges being informed of the guarantees and cost of each contract separately.
Please select at least one contract
5 Pre-contractual documents provided DDA Art. L.521-3
6 Client Declarations
All declarations must be checked
7 Electronic Signature
Required field
By submitting this form, the client certifies the accuracy of the information provided and confirms having received advice prior to any subscription, in accordance with Articles L.521-1 et seq. of the French Insurance Code.
Please correct the errors below before submitting.
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Form validated!
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Document generated via Ambrelia — Duty of Advice Form compliant with DDA / ACPR
Legal ref.: Art. L.521-1 to L.521-6 French Insurance Code — Directive (EU) 2016/97

Important :

Once all the information has been completed :

  1. Click on « Validate and generate the PDF »
  2. Then click on « Open email »
  3. Your email client will automatically open with the link to your file in PDF format
  4. Simply click to ” send ” submit your information to us

Without this final step, we will not be able to receive your application.

Our team will get back to you as soon as possible to finalize your application and answer any questions you may have.

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