CALLE DE SANTA ENGRACIA, 151 28003 MADRID, SPAIN

TEL: +34 611 249 513 FAX: +34 917 903 950
Leasing commission Agent, Sole Representatives, Contractors, & Security Services
Payment Verification and Release Department
LEGAL AUTHORITY / APPLICATION OF CLAIM
Reference N :
Amount :
First Name : Last Name : Date of Birth :
Marital status : Mobile : Telephone : Fax :
Address : Nationality : Occupation :
City : State : ZIP/Postal code :
I WANT TO BE PAID BY: A / BANK TRANSFER B/CERTIFIED CHEQUE
BANK INFORMATION (This is needed only for bank transfer)
Bank Name :
Bank Account Number : Bank Sort Code Or Routing Number :
Swift Code:
Bank Address : Bank Phone : Bank Fax :
City : State : ZIP/Postal code :
NEXT OF KIN
First Name : Last Name : Relationship with He/She :
Mobile : Telephone : Fax :
Address : Nationality : Occupation :
City : State : ZIP/Postal code :
DECLARATION
I Mr/Mrs--------------------------, here by declare that I have never received any payment insured on my behalf by
EUROFINANZZA SECURITY COMPANY S. A Nor have any of my family members filled a claim on my behalf . I here by
certify that the information given above is true and thereby give EUROFINANZZA SECURITY COMPANY authority to
process my winning fund.
Beneficiary Email: Signature : Date:
This form must be completed, and fax along with a photocopy of your identification to
EUROFINANZZA SECURITY COMPANY S. A on the above fax number.
Compaa De Seguridad ( Reg :Merc : Madrid 679 / 257 3 / 2012 )