Insurance details
Please write Policy number

Notifier’s data

Give us your email so we can send you a confirmation of filing your case

Data of car owner

Reason for termination

Reason why you want to cancel the insurance?
Fill in the details if you want to get a premium refund:

Attach a scan or photo of the withdrawal from the contract

To effectively withdraw from an insurance contract concluded remotely fill out and sign our template in your own hand - you can find it here.

Model

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