Life cover questionnaire

Please fill in the fields of this form. Then, one of our brokers will contact you as soon as possible to propose a quote adapted to your project and your profile. If you have a problem (sometimes computers Appledo not always validate the form), or if you want to share a feature that could not be reflected here, call us at +33 326 87 82 05, we will fill in together.


Number of person(s) to be insured : *



INSURED 2 or SPOUSE (if applicable)

Name *

First name *

Date of birth *

Country of residence for tax purposes

Nationality *

1* insured email

Postal address *
(Street, postal code, city, country)

Number of children :

Phone number *

Do you smoke?
(NO if you have not smoked for at least 2 years)

Profesional status

Occupation (exact title of job) *

Business travels by car

Frequent travel abroad for work?
(if yes, specify: country / city / annual frequency)


Purpose of the Life insurance *

Date on which you would like to be insured*.

If the payer is a company specify here: (legal form, name, address)

Death benefit to be covered (€)

Covers requested

Other desired options


Net annual income of the insured? (€) *

Specify if you think you need to declare a specific risk:

Quota to be insured per person *

Name of the person who recommendedValorama? *

Name of his company / Origin of the link? *

Commentary, specific requirement, details of the objective sought .


To be attached here for a quick and accurate processing of your request. Especially if you want to apply online or emergently (non-blocking).