Insurance cancellation form

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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

Relation number partner*

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

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

Label Why would you like to cancel?

Are you planning to emigrate? Don't forget to deregister with the municipality. Is your job or income in the Netherlands coming to an end? If so, please submit a pay stub or a statement from your employer as proof.

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Insurance cancellation form

Fill in the underlying form

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