Aplikasyon Asirans

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Enfòmasyon propoze Asire a
Prenon & Siyati propoze Asire a*
Prenon Siyati
Ki seks propoze asire a*
Dat nesans propoze asire a*
Date Format: MM slash DD slash YYYY
NIF propoze asire a
Eske propoze asire a fimen?*
Nimewo selilè propoze Asire a*
Emel propoze asire*
Emel propoze asire Komfime Mete Emel propoze asire
Adrès propoze asire a*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Zòn propoze asire a rete ladan'l*
Vil propoze asire a rete ladan'l*
Depatman propoze asire a rete ladan'l*
Eske propoze asire gen yon maladi ki pra l tiye li?*
Eske se yon plan pou timoun de mwens ke 15 an?*

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Mèt polis
Non mèt polis la*
Prenon mèt polis la Siyati mèt polis la
Dat nesans mèt polis la*
Date Format: MM slash DD slash YYYY
NIF mèt polis la*
Adrès mèt polis la*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Zòn mèt polis la rete*
Vil mèt polis la rete*
Depatman mèt polis la rete*
Telefòn mèt polis la*
Emèl mèt polis*
Emel propoze asire Komfime Mete Emel propoze asire
Ki relasyon ou gen avèk propoze asire a?*

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Kouvèti
Konbyen benefis ou vle aplike pou li?*
Si w chwazi yon lòt montan mete li
Konbyen prim propoze asire a ye e ki frekans de peman ( Ann grandi ansanm minimom se chak 3 mwa)*

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Ki jan w ap peye
Pa pran lajan nan men kliyan nan moman ou aplike pou kliyan
Ki metòd de peman w ap itilize?*
- Cashmobile
- Moncash
- Cashmobile & Moncash
Ki dat ou vle peye?*
- Dat yo pote polis la pou ou a?
- Yon lot / Other:
Ki frekans peman ou vle? Plan "Ann grandi ansan'm " minimòm chak 3 mwa*
- Chak mwa
- Chak 3 mwa
- Chak 6 mwa
- Chak ane

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Disclaimers
Consent*
I agree to the privacy policy.
Eksplike kliyan ke si li mouri avan 25 mwa, se lajan li te peye yo n ap remèt benefisye a. Fè mèt polis la ekri non li si li dakò*
Eksplike kliyan ke se lè ou delivre polis la pou li pou l peye. Ekri non mèt polis si li konprann sa*
Eksplike kliyan ke li blije peye plan toutotan propoze asire a ap viv.*

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Rapò ajan
Ki pyès idantite propoze asire a te ba w?*
Ajoute foto pyes propoze asire a
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Ajoute foto propoze asire a
Drop files here or

Accepted file types: jpg, gif, png, pdf.
Ki sikatris vizib ou wè sou propoze asire a?
Eske propoze asire a lopital?*
Eske se fanmi ou?*
Si se fanmi w, ekri non w pou endike ke ou konprann fraternite assurance pra l voye yon lòt ajan verifye propoze asire a avan nou aprouve polis la.
Mèsi pou biznis ou, FRASA ap fè tout dilijans li pou prosès aplikasyon e fè w jwenn li si li aprouve nan mwens ke 30 jou
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Enfòmasyon Ajan an