Care Concept AG • International Health Insurance for foreign guests and visitors • Care Economy • Service


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Care Concept AG
- Vertragsabteilung -

Postfach 33 01 51

53203 Bonn

Fax-no.: +49 (0)228 - 977 35 911 | e-mail:

19.06.2013

Change of direct Debit Authorization for Policy - LEZ Änderung Care Economy	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

Health insurance for foreigners in Europe