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//-->


<html>

<head> 

<title>D'hondt Insurance - offerte MyBike</title>
<link rel="stylesheet" href="style.css?v=1.6" type="text/css">
<link rel="stylesheet" href="sidenav.css" type="text/css">



<SCRIPT Language="JavaScript">

function HidePremie() {
	 var sElementID = document.getElementById('DisplayPremie');
     sElementID.style.display="none";
}


function HideMin50() {
	 var sElementID = document.getElementById('Min50Values');
     sElementID.style.display="none";
	 HidePremie();
}

function ShowMin50() {
	 var sElementID = document.getElementById('Min50Values');
     sElementID.style.display="";
	 HidePremie();
}


</SCRIPT>




</head>



<body bgcolor="#000000 text="#000000" leftmargin="0" topmargin="0" marginwidth="0" marginheight="0" bgcolor="#000000" background="MyBikeBackground.jpg" style="BACKGROUND-POSITION: center; BACKGROUND-REPEAT: no-repeat; BACKGROUND-ATTACHMENT: fixed; BACKGROUND-SIZE: cover">

<div align="center">


	<table height="100%" width="610" cellpadding="15">
		<tr valign="top">
			<td>

					<table width="100%" border="0" bgcolor="#FFFFFF"  class="bodytext" cellpadding="15" cellspacing="0">
						<tr>
							<td align="center" colspan="2"><img src="https://dice.dkpv.be/MyBike/MyBikeInsurance.png" height="80"></td>
							<!-- <td align="right"><img src="https://dice.dkpv.be/MyBike/D&G.png" height="70"></td> -->
						</tr>
						<tr valign="top">
							<td colspan="2">
							
						
								<table border="0" class="BodyText" cellpadding="5" cellspacing="0" width="100%">
									<form name="OfferteForm" method="Post" action="?">
									
								
										<tr valign="top">
										</tr>
								
										<tr valign="top">
											<td align="left" colspan="2">
												MyBike verzekeringsvoorstel
											</td>
										</tr>
								
								
										
	
										<tr height="100"><td colspan="3" class="header">Verzekeringsnemer</td></tr>

										<tr valign="top"> 
										  <td align="right">Voornaam *</td>
										  <td><input type="text" name="KlantVoorNaam" size="25" value=""></td>
										</tr>
										<tr valign="top"> 
										  <td align="right">Naam *</td>
										  <td><input type="text" name="KlantNaam" size="25" value=""></td>
										</tr>

										<tr valign="top"> 
										  <td align="right">Straat *</td>
										  <td><input type="text" name="KlantStraat" size="25" value=""></td>
										</tr>
										<tr valign="top"> 
										  <td align="right">Huisnummer *</td>
										  <td><input type="text" name="KlantHuisNr" size="5" value=""></td>
										</tr>
										<tr valign="top"> 
										  <td align="right">Bus</td>
										  <td><input type="text" name="KlantBusNr" size="5" value=""></td>
										</tr>
										<tr valign="top"> 
										  <td align="right">Postcode *</td>
										  <td><input type="text" name="KlantPostCode" size="10" value=""></td>
										</tr>
										<tr valign="top"> 
										  <td align="right">Gemeente *</td>
										  <td><input type="text" name="KlantGemeente" size="25" value=""></td>
										</tr>
										
										<tr valign="top"> 
										  <td align="right">Land</td>
										  <td><input type="text" name="KlantLand" size="25" value=""></td>
										</tr>
	
										<tr valign="top"> 
										  <td align="right">BTW-nummer</td>
										  <td>BE <input type="text" name="KlantBTWnr" size="25" value=""></td>
										</tr>
	
	
	
										<tr valign="top"> 
										  <td align="right">e-mail *</td>
										  <td><input type="text" name="KlantEmail" size="25" value=""></td>
										</tr>
										
										<tr valign="top"> 
										  <td align="right">Telefoon</td>
										  <td><input type="text" name="KlantTel" size="25" value=""></td>
										</tr>


										
										<tr height="100"><td colspan="2" class="header">Fiets</td></tr>

										<tr valign="top"> 
										  <td align="right">MyBike vestiging *</td>
										  <td>
						  					<select name="MyBikeVestiging">
												<option value="" selected>-- selecteer --</option>
												<option value="MYBIKE BRUGGE"  >MYBIKE BRUGGE</option>
												<option value="MYBIKE LEDE"  >MYBIKE LEDE</option>
											</select>
											
										  </td>
										</tr>

										<tr valign="top"> 
										  <td align="right">Type *</td>
										  <td>
						  					<select name="FietsType">
												<option value="" selected>-- selecteer --</option>
												<option value="e-bike"  >e-bike (stads-, race-, MTB- en bakfiets)</option>
												<option value="speed pedelec"  >speed pedelec</option>
												<option value="cargofiets"  >cargofiets</option>
											</select>
											
										  </td>
										</tr>

										<tr valign="top"> 
										  <td align="right">Merk *</td>
										  <td><input type="text" name="FietsMerk" size="25" value=""></td>
										</tr>
										
										<tr valign="top"> 
										  <td align="right">Model *</td>
										  <td><input type="text" name="FietsModel" size="25" value=""></td>
										</tr>
										
										<tr valign="top"> 
										  <td align="right">Bouwjaar *</td>
										  <td><input type="text" name="FietsBouwjaar" size="5" value=""></td>
										</tr>
										
										<tr valign="top"> 
										  <td align="right">Framenummer *</td>
										  <td><input type="text" name="FietsFrameNummer" size="25" value=""></td>
										</tr>

										<tr valign="top"> 
										  <td align="right">Waarde *</td>
										  <td>&euro;&nbsp;<input type="text" name="VerzekerdeWaarde" size="10" value=""></td>
										</tr>

										
										<tr height="100"><td colspan="2" class="header">Waarborgen</td></tr>

										<tr valign="top"> 
										  <td align="right">Waarborg</td>
										  <td>-Omnium (vrijstelling € 50)<br>-Bijstand (België + 30 km)
										  </td>
										</tr>

										

							
								</table>

							</td>
						</tr>
						<tr>
							
							<td colspan="2">
								<table width="100%" border="0" class="headerwhite" cellpadding="10" cellspacing="0" bgcolor="#282726">
										
										<tr height="50"><td class="headerwhite">Premie</td></tr>

								
										
										<tr valign="top" > 
										  <td align="center">
											<input type="submit" name="BerekenPremie" value="Bereken uw premie">
										  </td>
										</tr>

										<tr height="10"><td></td></tr>

										
										
					

											<tr valign="top" id="DisplayPremie" > 
											  <td><br>
													
												<br>
											  </td>
											</tr>
								
										
								

								</table>
							
							</td>

						</tr>
					</table>


			</td>
			<td>
			</td>
		</tr>
	</table>
</div>





</body>