Proposal Group insurance for salaried workers Intermediary : B C A Name: Contact person: E-mail adress: Information about the offer Offer number : / / Staff category to be insured : Has the employer or any allied company already taken out a group insurance for salaried workers with Allianz? Group number : Should the new group insurance be made out in the same way as the existing one? Group number : Changes with respect to the offer? If yes: brief description of the differences: Employer s identification General data Company number:.. Company name : Legal form: Language : l NL l FR Address: No: Box : Postal code : Place : Country : Contact person : Madam Miss Sir Other: Name : First name : E-mail address : Phone number : Fax number : Articles of association : Belgian Official Gazette of page nos: Compulsory for employers with a registered office abroad There is a branch in Belgium. There is an establishment in Belgium. Establishment n. : There is a permanent presence* in Belgium. there is neither a branch, nor an establishment or a permanent presence in Belgium.** * a subsidiary, an agency, a permanent establishment, a production unit, etc. (entities that are normally subject to the tax payable by non-residents (companies). ** only in this case does the Employer benefit from the waiver of Belgian premium tax. Postal address if different from the registered office address Name : Adress : No: Box : Postal code: Place: Contact person : Madam Miss Sir Other: Name : First name : E-mail address : Phone number : Fax number: Manner in which the pension regulation has been created l by the employer s ex parte decision l through a collective labour agreement concluded in the company (please attach a copy of this CLA to this document) l through an amendment to the labour regulation (please attach a copy of this regulation to this document) l through the procedure laid down in article 12 of the Belgian law on supplementary pensions (LCP) According to the Belgian law on supplementary pensions, group insurance can be implemented by a mere ex parte decision by the employer unless the plan in question covers all members of staff and provides for personal contributions by all those covered. In that case, the implementation must be carried out via a CLA or via an amendment to the labour regulation, if there is no trade union deliberative body present in the company. But all the same, plans that can be legally implemented through an ex parte decision by the employer can also be created via a CLA or an amendment to the labour regulation within the context of the social deliberative structure. Article 12 of the LCP deals with the specific case in which a social plan is introduced and the company has no trade union deliberative bodies.
Specific characteristics of the group insurance Is this group insurance taken over from an existing group insurance or pension fund? If yes, please enclose a copy of the document 'information about the change of pension institution' that was sent to the FSMA. This document is available on (only in Dutch or French) http://www.fsma.be/~/media/files/fsmafiles/circ/nl/2004/wap_3.ashx) Is this group insurance an opting out of a sector pension commitment? If yes, please fill in the information below : Number of the Joint Committee for which a sector plan exists : Sigedis identification number for the sector plan : - - - - - Refusal to take part in the group insurance Are there any staff members who refuse to take part in the group insurance? If yes, how many members of staff refuse to take part? List the information for the staff members concerned below and attach the signed weigering tot aansluiting (refusal to take part) document to the present document. Name First name Date of birth National Registry Number Sex Membership conditions l please specify if a minimum age is applicable : l please specify if membership is subject to a waiting period : Important remark about membership conditions: membership can never be postponed until the member's 25th birthday pursuant to the application of membership conditions. Membership documents and medical questionnaires, if any The completed membership forms are : l enclosed l forwarded on electronic carrier. Date: / / E-mail address : Please use the group insurance membership document (with option) for a plan with options. Please use the group insurance membership document (without option) for a plan without options. Please use the membership document Easy Plan for an Easy Plan. Medical questionnaires : l are filled out by the members and are enclosed l are sent to the members l still have to be forwarded by Allianz. The different forms are available on http://gidseb.allianz.be/nl/paginas/default.aspx. Ownership of the reserves The reserves built up by the employer's contributions are only owned by the member after one year of membership. l No, the reserves are immediately acquired. Starting date and periodical due date Effective date : 0 1 / / Date of the annual update : 0 1 / Expiry age : 65 Method of premium payment The premiums are payable in monthly portions upon expiration. l single premium : (only for the purpose of funding past years of service) l years of service with the employer : l years of service with previous employers :: l unlimited or l 10 years or l as from 0 1 / / l limited to months Payment modalities : l domiciliation l transfer to the financial account of the company The premium statements are never collected via the producer's account.
Instructions for document dispatching When starting the group insurance, all documents (regulations, addenda and individual pension documents) are sent to the intermediary. Afterwards all documents are sent to the employer. The premium statements are available on the collaboration platform of the webtool '@line'. Kindly specify in the table hereunder any changes you want to make in the standard procedure, by ticking the preferred addressee for each type of document. Document type Intermediary Employer Annual calculation l l Correspondence l l The regulation has already been printed in @line pro (only possible for Easy plan) and the employer has enclosed the signed copy : Clauses Kindly give a brief description of any specific clauses you wish to insert in the regulation : Declaration of a company representative Has the company already taken out a group insurance for the same category to be insured? If yes, with which insurer? Insurance company : Reference number: Does the company have the intention to change or terminate this insurance? If yes, why? Is there a person in the company, among the shareholders or the managers, active or not, who holds or has held a mandate or a political public position on regional, national or international level? The company representative declares to be informed of the wordings overleaf. Name : ID card no*: * Please attach a front and back copy of the ID card of the company representative(s) to the signed proposal. Position : Signature of the company representative: (preceded by the handwritten statement: "Read and approved") Company stamp Made out in on The present proposal, completed and signed, must be sent together with the supporting documents to Allianz Benelux n.v., to the attention of the department Voorzorg (10A1PP). The document can also be sent by mail to voorzorg@allianz.be.
Legal provisions This document is a life insurance proposal. This proposal obliges neither the insurance company nor the prospective party insuring to sign the contract. If the company fails to send the prospective party insuring an insurance offer or to inform him about the fact that the insurance is subject to a questionnaire or about the refusal of the insurance, and this within 30 days following the receipt, she undertakes to conclude the contract under penalty of compensation. No premium or any other amount whatsoever, even a provisional one, can be claimed for a life insurance or a complementary insurance before the subscription of the contract. Pursuant to article 7 of the 14 November 2003 Royal Decree on life insurance activities, published in the Belgian Official Gazette of the same date, Allianz Benelux N.V. shall recover the expenses for the medical examination from the prospective party insuring, if the latter does not subscribe the contract or the addendum for higher insured amounts, or if he terminates the contract within 30 days after taking effect. Termination, reduction or surrender of a life insurance in order to take out another life insurance is generally disadvantageous to the party insuring. DB2P - Supplementary pensions database Allianz uses this document to input information into the supplementary pensions database (DB2P). The obligation to report rests with the insurance company. Allianz bases the report on the declarations made by the employer and can therefore not be held liable for the reporting of incomplete, incorrect or late information. If the employer does not provide certain information, Allianz cannot in that case, as an insurance company, comply with its legal obligations and the Employer runs the risk of losing the tax deductibility of the premiums. The legislation with regard to the second pillar database originates from Articles 305 and 306 of the programme law of 27/12/2006 and the Royal Decree of 25/04/2007 implementing Article 306 of the programme law of 27/12/2006. More information can be found on www.sigedis.be and www.db2p.be. Protection of private life and the rights of persons on whom data have been recorded Data of a personal nature communicated to Allianz Benelux n.v. exclusively serve the following purposes: assessment of the risks insured, management of the commercial relation and management and execution of the insurance policy and claims insured under the policy, portfolio control, abuse and fraud prevention. For these exclusive purposes the data can be transmitted to a reinsurer, an adjuster or a legal adviser. Access to these data is granted to the acceptance and claims handling departments, to the Legal and Compliance department in the context of a dispute, if any, or for control purposes, and to the Audit department in the strict context of the tasks it has been charged with. The insured person herewith consents to the processing of his personal medical data by the Medical department and the abovementioned persons, if that turns out to be necessary in the context of policy or claims management. The insured person accepts the party insuring and the intermediary to have knowledge of the policy contents and the exclusions, if any. Depending on the circumstances, failure to communicate the required personal data may trigger the impossibility for Allianz Benelux n.v. or its refusal to start a commercial relation, to continue such relation or to execute an operation requested by the person involved. Anyone demonstrating his/her identity is entitled to obtain communication of the data contained in the file on him/her. To exercise this right, the person involved addresses a dated and signed application to the service: Protection of Private Life, Allianz Benelux n.v., Lakensestraat 35, 1000 Brussel. This application shall include a copy of the identity card of the person applying and shall mention the name and address of the doctor to whom our medical advisor can communicate medical information. Moreover, this person is entitled to obtain the correction or elimination of this data free of charge if they are not accurate. He can also oppose to the use of these data for direct marketing purposes by explicitly mentioning it next to his signature on this document. Warning Any fraud or attempted fraud to the detriment of the Insurance Company shall not only lead to immediate cancellation of the policy, but also to prosecution in execution of Article 496 of the Criminal Prosecution Code. The person who has committed fraud or attempted to commit fraud will moreover be listed in the E.S.V. Datassur file, de Meeûssquare, 29 1000 Brussel, that keeps record of those risks to be closely watched over by the affiliated insurance companies. Complaints handling The Belgian law is applicable to the insurance agreement. Any complaint regarding the execution of the agreement should be lodged with: Ombudsman van de Verzekeringen, de Meeûssquare, 35, 1000 Brussel, tel. 02/547.58.71, fax: 02/547.59.75, info@ombudsman.as or Ombudsdienst van de maatschappij Allianz Benelux n.v., Lakensestraat,35, 1000 Brussel, fax: 02/214.61.71, klachten@allianz.be, without prejudice to the insured person's possibility to take legal action. Important The following documents must be attached to the present insurance proposal: For legal persons : The last co-ordinated or the updated articles of association filed with the Court of Commerce registry or published in the addendum to the Belgian Official Gazette. The updated list of directors. The publication of the appointment of the directors in the Belgian Official Gazette or any other document evidencing that capacity (annual report, an authentic document,...) The latest publication in the addendum to the Belgian Official Gazette of the legal person's delegation of powers. Moreover, the identification of the shareholders, directors or managers of the legal person should be evidenced by one of the following documents: the register of partners (for partnerships); the nominative register of shareholders (for companies with share capital); the attendance register of the last and the last but one General Meeting; any similar document deemed to be valid evidence. For company representatives: a front and back copy of the ID card and a valid proof of address of the signatory/ies of the proposal authorized to sign contracts on behalf of the legal person. Holders of an Electronic identity card (eid) should attach a front and back copy of the card and of the accompanying document 'proof of address' they received from communal authorities when their eid was issued. Allianz Benelux s.a IBAN: BE74 3100 1407 6507 Insurance company licensed by the NBB (National Rue de Laeken 35 BIC: BBRUBEBB Bank of Belgium) under code no 0097 for Life 1000 Bruxelles VAT: BE 0403.258.197 and Non-Life business Tel.: +32 2 214.61.11 RLP Brussels NBB Head Office: Fax: +32 2 214.62.74 www.allianz.be Boulevard de Berlaimont 14, 1000 Bruxelles, www.nbb.be V892EN 150921
Document to be filled out and returned by mail : EBOnline.technicalsupport@allianz.be New request Change of an existing situation Application for access to the collaboration platform and @line Company name : Contact person : Ms/ : E-mail : Tel. : Select one choice only Name E-mail Smartphone /Tel. App Dig Full + SAL Full SAL Acc. Lim. N S M Fr Nl * only to adapt an existing situation Dig App Digipass device Digipass mobile app for smartphone Made out on : Signature and name of the person in charge Full + SAL Full SAL Acc. Lim. Full access : all functions with salary list Full access : all functions without salary list Accounting access : only invoices, grouped payments and NSSO Limited acces : only grouped payments and NSSO N S M New user Cancellation of an existing user Modification of access permissions Allianz Benelux s.a. Rue de Laeken 35 1000 Bruxelles Tel.: +32 2 214.61.11 www.allianz.be VAT: BE 0403.258.197 RLP Brussels Insurance company licensed by the NBB (National Bank of Belgium) under code no 0097 for Life and Non-Life business NBB Head Office: Boulevard de Berlaimont 14, 1000 Bruxelles, www.nbb.be - V892