Insurance cancellation form

Fill in the underlying form

Initials* Inserts Surname* Date of birth* Relation number (You can find your relation number on your policy or in the welcome email you may have received)* Email adress* Phone number*

Does the cancellation also count for your partner?* Yes No

Policy number partner*

Does the cancellation also count for your child(ren)?* Yes No

How many children?

Policy number child 1*

Policy number child 2*

Policy number child 3*

Policy number child 4*

Policy number child 5*

Policy number child 6*

Starting from which date would you like to cancel the policy? 1st of January of the comming year other date

Date cancellation* Why would you like to cancel? Explanation