GDPR COVER application form

Please fill up the application form below and we will send You GDPR Policy Draft and contact You asap.

Full name of Company*

Full address of Company*

Email*

Contact person*

Annual Turnover (consolidated)*

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Company Certification*

If the Company has a certification that is accredited by the Supervisory Authority, please select YES, otherwise please select No.

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Verification of data*

On behalf of the Company, as at the date of signing of this document, the statements in Annex 1 are confirmed as true: Read Annex 1 http://colemont.lt/wp-content/uploads/2018/03/General-Data-Protection-Regulation-insurance_Annex-1.pdf

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Is the Company regarded as*

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Company data protection breach info*

Has the Company been in breach of any local or international privacy / data protection laws during the last 5 years?

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Financial Products*

Does the Company provide Financial Products?

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Health Care Services*

Does the Company provide Health Care Services as referred to in Directive 2011/24/EU?

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Personal Data*

Does the Company hold Personal Data in, Yes No or communicate Personal Data to or from, any country outside the EU?

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Insurance Inception date*

For more information please contact:

Marius Gaidamavičius Underwriting Specialist M + 370 637 82321 T + 370 5 210 9660 E marius.gaidamavicius@colemont.lt

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