Care Concept AG
– Policy Department –
P. O. Box 33 01 51

53203 Bonn


Fax.: 0800 977 35 35   |   e-Mail:  info@care-concept.de


 Termination of the Policy
Policy number

Policyholder
Insured person
born on:

Contact information
| | - |

  Dear Sir or Madam,

  I hereby give notice of termination of the above-mentioned insurance policy,
  effective as of .... or at the earliest possible date. Please send written
  confirmation of termination of the policy to the above-mentioned address.

  Originally contracted expiration date of the policy is .... .

I will transfer/transferred to the compulsory health insurance on... . Reason:
I will end/ended my stay abroad on... . An appropriate certification (e.g., travel documents) is enclosed.
I will end/ended my stay abroad on... . As the departure will take place/took place on , documentation cannot yet be provided.

Faithfully yours,

 ________________________________

________________________________

Date, signature of the insured person
(bei minderjährigen Personen Unterschrift des gesetzlichen Vertreters)

Policyholder’s signature