Care Concept AG • Private Krankenversicherung für Sprachschüler u. Studenten • Care College • Service


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

Care Concept AG
- Vertragsabteilung -

Postfach 33 01 51

53203 Bonn

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

21.05.2012

Direct Debit Authorization for Policy - LEZ Care College	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,

I hereby grant you, subject to revocation, a direct debit authorization for the premiums due for the
above-mentioned insurance policy.

Please debit directly the following bank account for premiums due in the future.

**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