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Collective Mutual

Quote sheet

Name of representative *

Representative’s first name *

Representative phone *

E-mail address *

Number Siret

Company Name *

Postal code

City *

Are you affiliated to a collective agreement?

If yes, indicate your IDCC number

Enter your NACE code( le code NACE est indiquée sur la fiche de salaire )

Is there a unilateral decision by the health and welfare employer?

If yes, check (if modification or implementation.)ModificationSet up

Indicate the date of entry into force of the decision

Indicate the share of distribution of the contribution in %:

Employer's contribution

Salary Share

Who will be insured?

Would you also like to subscribe to a pension plan?

Number of executives

Average age of executives

Number of non-executives

Average age of non-executives

Number of children dependent on staff

Common medicine consultation

Hospitalization

Optical

Dental

Do you currently have health coverage?

Si oui est ce que vous l’avez depuis plus de 12 mois ?

Indicate the anniversary date of your contract.

Enter additional information if necessary

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