REQUEST NOT TO RENEW THE

POLICY / PRODUCT / BENEFICIARIES

PART OF

SANITAS S.A. DE SEGUROS Ribera del Loira, 52 28042 Madrid Tax no.: A28037042 COPY FOR SANITAS

Policy number 84073223

Specify request type Policy Beneficiary Product
Product Cancellation
* Fill in for Product Cancellation.

Personal Details of the Policyholder

POLICYHOLDER:
Surname
Balazs Middle Name

Name
Talas Telephone no.
+36703649961
Landline Mobile
ID Document nº 457713TA ✔ ID no./Tax no. Passport Residence permit no.

Email bowlyblaise@gmail.com

Beneficiary’s Details

* Fill in for requests not to renew a Beneficiary or an Individual Product.

Surname
Balazs Middle Name

Name
Talas

Surname Middle Name

Name

Surname Middle Name

Name

Reasons for requesting NON renewal

Change of residency

The undersigned accepts that the non-renewal requested will not come into effect until the date the insurance contract expires and provided that there
is at least one monthly instalment between submitting this non-renewal document and the expiry date.

Your personal data will be processed by SANITAS S.A DE SEGUROS (Sanitas), with registered offices at C/ Ribera del Loira, 52, 28042 Madrid,, Spain, in
order to manage your cancellation request (implementation of a contract). The data will generally be stored for at least 5 years. You have the right to
access, rectify and erase the personal data, as well as the other rights set out in the applicable regulation. For more information about your privacy, go
to: https://www.sanitas.es/rgpd.

Signature of the Policyholder / Insured Lorem ipsum Signature of the Agent/Company

In
Hungary on
the 9th of May 20
23

Important Do not forget to stamp this form.