Contract Merger / Family Reunification Form

Personal details of the main policyholder or head of the household

This field must be filled out

First name

This field must be filled out

Last name

This field must be filled out

Insurance no.

This field must be filled out

Address

This field must be filled out

Postcode

This field must be filled out

City

This field must be filled out

Date of birth

This field must be filled out

Phone

This field must be filled out

Mail

This field must be filled out

Will more than two people be included?*

Yes

This field must be filled out

Additional people

This field must be filled out

Number of additional people

This field must be filled out

Full first and last name*

This field must be filled out

Insurance number*

This field must be filled out

Nein

Additional person

This field must be filled out

Full name

This field must be filled out

Insurance number

This field must be filled out

Bank/Postal account details

This field must be filled out

Have your bank account or post office account details changed as a result of the merger?*

Yes

This field must be filled out

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

This field must be filled out

IBAN-no.

This field must be filled out

Account holder

This field must be filled out

Who will cover the payment?

This field must be filled out

Comments

This field must be filled out

HIN encryption

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

This field must be filled out

* 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.

This field must be filled out

Zurueck