Versicherungsbüro Dr. Nemling
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Rotary Travel Insurance - Registration Form
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Rotary Travel Insurance - Registration Form
Insured person
name
*
sex
*
male
female
address
*
street
address - 2nd line
postal code, city, country
date of birth
*
place of birth
*
nationality
*
social insurance carrier
private health insurance policy number
inception date
*
Email
*
a copy of submitted data will be sent to this account
Endabschnitt
Payor details
name
*
e-mail
Endabschnitt
Calculation of applicable fee
premium
*
term of insurance in days (min. 31 days - € 40,30) by 1,30 daily rate
bank transfer fees
*
Latin America 26 €, overseas and Europe(non SEPA countries) 16 €, SEPA countries 2€
total fee
premium plus bank fees
Endabschnitt
Payment details
transferring institution
for easier payment processing please provide your bank's name
date of transfer
*
please provide the date when the transfer was performed
whaterver is on your mind
Untitled
Endabschnitt
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