Register - Loonzorg
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REGISTRATION FORM

  • PARTICULARS POLICYHOLDER

  • ADDRESS DETAILS (YOUR ADDRESS IN THE NETHERLANDS)

  • BANK ACCOUNT DETAILS

  • By signing this mandate form, you authorise LoonZorg B.V. to send recurrent collection instructions to your bank to debit your account concerning the monthly premium and your bank to debit your account on a recurrent basis in accordance with the instructions from LoonZorg B.V. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Ask your bank for the conditions.
  • By sending this form to LoonZorg B.V., applicant authorises LoonZorg B.V. to register the person stated above for the HollandZorg no risk policy. The policy will be effective after receipt of the first monthly premium. This application is only valid after receipt of a copy passport in combination with an employer’s declaration or recent salary slip. LoonZorg has the right to end the insurance as from the date the insured stopped working for current employer