Contract separation/family separation form

Information on the person leaving

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First name

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Last name

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Insurance no.

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Address

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Postcode

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City

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Date of birth

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Phone

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Mail

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Contract separation expected as of

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Please note: the date must be in the future and be the 1st day of the month.

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Additional persons leaving the policy

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Are additional persons leaving the family policy?

Yes

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Number of additional people

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Full first and last name*

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Insurance number*

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Bank/Postal account details

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Have your bank/postal account details also changed with your leaving the policy?

Yes

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If so, please state your new IBAN no. and the account holder here.

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IBAN-no.

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Account holder

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Comments

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HIN encryption

I would like to receive any documents via HIN-encrypted message.

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* Required field

The information provided will not be passed on to third parties. These data will only be stored and used to process the relevant matter.

By submitting the form, you confirm that you have acknowledged and accepted the Data protection notice.

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