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Freedom Security
Freedom Health
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Insured event
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REGISTRATION
Who will we insure/the policyholder?
Enter IIN
Enter IIN
Enter your full name
Enter your full name
Gender
Gender
Date of birth
Date of birth
Phone
Phone
Email to receive the policy:
Email to receive the policy:
Residence address: street, house, apt.
Residence address: street, house, apt.
Document, identifying a person
Document type
Document type
Document number
Document number
Date of issue of the document
Date of issue of the document
Issuing Authority
Issuing Authority
Insured sum and payment method
Insurance period (months)
Insurance period (months)
Insured sum:
Insured sum:
To pay:
To pay:
Promo code
Promo code
Promo code
I confirm compliance and consent with the terms
of declarations
I give my consent for collection and processing of personal data and I am familiar with the
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