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GOLDENCARE OFFER for     Private client Broker

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Title :	M Mrs Miss	Marrital Status :	Single Married Divorced Widow
Family name :		First name :
Birthdate :	01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Nationality :	Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina-Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Channel Islands Chile China Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt Equatorial Guinea Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands (Malvinas) Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haïti Holy See Honduras Hong Kong (U.-K.) Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kurdistan Kuwait Kyrgyzstan Lao Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mayotte Mexique Micronesia Moldavia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of Croatia Republic of Kenya Republic of Korea Republic of Mauritius Republic of Yemen Reunion (Fr) Romania Ruanda Russian Federation Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and Grenadines Salvador Samoa San Marino Sao Tome and Principe Saudi Arabia Sénégal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Tadjikistan Taiwan Tanzania Tchad Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Virgin Islands Uruguay USA Uzbekistan Vanuatu Venezuela Vietnam Wales Wallis and Futuna Islands Western Sahara Yugoslavia Zaire Zambia Zimbabwe
Address of correspondence :
Zip Code / City :	/	Country :	Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina-Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Channel Islands Chile China Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt Equatorial Guinea Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands (Malvinas) Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haïti Holy See Honduras Hong Kong (U.-K.) Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kurdistan Kuwait Kyrgyzstan Lao Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mayotte Mexique Micronesia Moldavia Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Republic of Croatia Republic of Kenya Republic of Korea Republic of Mauritius Republic of Yemen Reunion (Fr) Romania Ruanda Russian Federation Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and Grenadines Salvador Samoa San Marino Sao Tome and Principe Saudi Arabia Sénégal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Tadjikistan Taiwan Tanzania Tchad Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Virgin Islands Uruguay USA Uzbekistan Vanuatu Venezuela Vietnam Wales Wallis and Futuna Islands Western Sahara Yugoslavia Zaire Zambia Zimbabwe
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PARTY TO BE INSURED

Please complete the table below whilst taking into account the following factors :

- Zone 1 : Worldwide but limited to 30 days per year in the United States, Caribbean and Canada - Zone 2 : Worldwide - As a contracting party you can decide not to be insured Would you like to be insured ? Yes No

Surname	First name	Sex M/F	Nationality	Date of birth	Protection zone	Contribution
				Zone 1 Zone 2

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