Application for cancellation of insurance

Policy and policyholder details

Policy number:CR-90033752039263D

VIN code of the vehicle: KL1JF68E9CK592200

Last name, first name / Name (and legal form) of policyholder:

Birth Number / Tax ID: 9209261732

Phone / Email: +420777201623/cyprainlioneljr@gmail.com

Correspondence Address:cyprainlioneljr@gmail.com

Bank Account Number:123-1434030287/0100

Reason for termination of contract

Tick the reason for cancellation and your chosen method of refund.
Termination after conclusion of the insurance contract
Termination after an insurance claim.
Termination by the policyholder at the end of the policy period.
Vehicle has ceased to physically exist / has been scrapped from the records. Annex: copy of record of disposal / scrapping.
Disposal of the vehicle. Annex: police report of vehicle theft.
Other: NOT USEFUL

Method of refunding premiums

X By bank transfer to the policyholder's account.

To the policyholder through an intermediary.

To the account of the intermediary/dealer.

Please send the completed form electronically to the address of the administrator: info@defendinsurance.eu, or to the address of
the administrator DEFEND INSURANCE s.r.o., Spáčilova 569, 767 01 Kroměříž. If the insurance premium is to be refunded through an
intermediary, please contact us immediately. inform us immediately of any delay in the payment of the premium or in the event of
any disputes in connection with the refund of the premium.
The intermediary may request a copy of this request.
Any questions, comments or complaints can be directed to us at info@defendinsurance.eu.

Date:03/03/2023

Signature of the policyholder: