Client Needs Assessment Form

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Client Details

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Please complete your personal details. This information is used exclusively for the purposes of your insurance file.

Surname *

First Name *

Father's Name

Date of Birth *

ID Card / Passport Number *

Greek Tax ID (AFM)

Greek Social Security No. (AMKA)

Home Address *

City *

Postal Code

Region / Prefecture

Mobile Phone *

Landline Phone

Email *

📄 Your compliance documents will be sent automatically to this email address.

Marital Status *

Number of Dependent Children

Employment Status *

Occupation / Specialisation

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Existing Insurance Coverage

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Important: Recording your existing insurance policies is necessary so we can recommend appropriate solutions without duplication of cover (Law 4583/2018, Article 30).

Do you already hold any active insurance policies? *

Yes No

If yes, please select the types of insurance you currently hold:

Life Health / Hospitalisation Accidents Motor – Compulsory Third-Party Liability Motor – Comprehensive / Fire / Theft Home / Property Business Civil / Public Liability Travel

Insurance Company (existing policies)

Reason for contacting an insurance intermediary *

I am looking for new insurance cover Renewal or change of insurance company Improving existing coverage Reducing premium cost Recommendation from a third party Other

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Insurance Needs Analysis

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Please select the types of cover you are interested in and add any comments or specific requirements. This helps us identify the most suitable insurance products for you.

🔵 Life Insurance

Death cover (family protection) Savings / Pension plan Endowment / Whole of life Lump-sum capital formation

🟢 Health & Accident Insurance

Hospitalisation Outpatient medical care / diagnostic tests Critical illness cover Accidents (permanent disability, medical expenses) Income protection / disability cover Group health insurance (for employees)

🚗 Motor Insurance

Compulsory third-party liability Fire / Theft Comprehensive cover Roadside assistance Legal protection (motor)

🏠 Home / Property Insurance

Fire & allied perils Earthquake Burglary / Theft Flood / Natural perils Property civil liability Landlord / Rental property cover

🏢 Business Insurance

Business property / premises Public / third-party liability Professional indemnity (E&O) Business interruption / loss of income Cyber insurance Goods in transit / cargo

Other needs or comments

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Financial Profile & Preferences

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This information is used exclusively to evaluate suitable insurance products (Article 20 of Law 4583/2018).

Annual Individual Gross Income *

Monthly Budget for Insurance Premiums *

Preferred premium payment frequency

Annual (lump sum) Half-yearly Quarterly Monthly

Risk tolerance *

Low – I prefer comprehensive cover with a low or no excess Medium – Balance between cover and cost High – I accept a higher excess in exchange for lower premiums

What is most important to you? *

Broadest possible cover, regardless of cost Balance of cover and premium Low premium with basic cover

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Health & Medical History

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This section is primarily relevant for life and health insurance. If you are not interested in these lines of cover, you may proceed without completing it. Health data is protected as sensitive data under GDPR.

Smoking status *

Non-smoker Smoker Ex-smoker (quit > 12 months ago)

Do you suffer or have you suffered from a chronic condition, serious illness or disability? *

No Yes – details will be provided in the Risk Disclosure Form

Do you participate in high-risk sports or professional activities?

No Yes (e.g. skydiving, motor racing, mountaineering, scuba diving, etc.)

Additional health comments (optional)

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Data Protection & Declarations

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Notice pursuant to Regulation (EU) 2016/679 (GDPR) – Article 13

Your insurance intermediary, B. PANOUTSOPOULOS & CO. G.P. (PROBITY Insurance Brokers), Klaudiou Galinou 16, 15127, Melissia, is the Data Controller of your personal data. The data collected is used exclusively for: (a) assessing your insurance needs; (b) concluding and managing insurance contracts; (c) fulfilling legal obligations.

You retain the rights of access, rectification, erasure, restriction of processing, data portability and objection. You may exercise them by contacting us at info@probity.gr.

Sensitive health data (Article 9 GDPR) is processed only with your explicit consent or as necessary for the performance of a contractual obligation.

Intermediary Remuneration Notice – Article 19 of Law 4583/2018

We inform you that your insurance intermediary is remunerated by way of commission paid by the insurance companies, which is included in the premium. No additional fee is charged to you for our intermediation services.

Conflicts of Interest Statement – Article 17 of Law 4583/2018

The insurance intermediary declares that no conflict of interest exists that could adversely affect your interests. Should any conflict arise, you will be notified immediately.

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Statutory Declaration & Submission

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STATUTORY DECLARATION
(Law 4583/2018 & IDD Directive 2016/97/EU)

I declare, under my personal responsibility, that:

1. All information provided in this form is true, complete and accurate.

2. I have not concealed any information material to the assessment of the insurable risk.

3. I am aware that inaccurate or incomplete disclosure may affect the validity of any insurance contract concluded.

4. I agree with the needs analysis carried out on the basis of the information I have provided.

Date of Completion *

Place of Completion

✅ By clicking "Submit Form", your details are sent automatically to PROBITY. No further action is required.

How would you like to proceed?

Basic Details

Refusal Declaration

Declaration submitted!

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