Care Concept AG | Au-Pair | Einzugsermaechtigung zur AuPair Versicherung Care Au-Pair

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

53203 Bonn

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

Direct Debit Authorization for Policy	Policy number

**Policyholder**

**Insured person**
	born on:

**Contact information**
\| \| - \|

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