Care Concept AG • Private Krankenversicherung für Residenten, längere Reisen mit weltweiter Deckung • Care Expatriate • Service


		Ihr zuverlässiger Partner für Krankenversicherung im Ausland Ausländer in Europa Deutsche im Ausland Reisende weltweit

Care Expatriate Health insurance for expatriates	Service

Care Concept AG
- Vertragsabteilung -

Postfach 33 01 51

53203 Bonn

FAX: +49 (0)228 - 977 35 911 | E-Mail:

17.05.2012

Change of direct Debit Authorization for Policy - LEZ Änderung Care Expatriate	Policy number

Policyholder

Salutation	First name	Last name

Insured person

Salutation	First name	Last name	born on:

Contact information

Street , no	c/o	Postal code	City	Country

Dear Sir or Madam,

My bank details for the direct debit mandate I issued for the above insurance policy have changed.

Effective please debit the premiums due from the following bank account:

**Bank account**
Bank name	Account holder	___________________________ Account holder’s signature
Sort code	Account number	___________________________ Account holder’s signature

Faithfully yours,

________________________________
Policyholder’s signature

Krankenversicherung für Ausländer in Europa