Enter your new bank or post office account details below. This will ensure there are no delays in reimbursing costs.

Insurance no.*

First name*

Last name*

Address*

Postcode*

City*

Telephone

E-mail*

IBAN-no.*

Account holder

Change valid as of*

Comments

HIN encryption I would like to receive any documents via HIN-encrypted message.

* Required field

The information provided will not be passed on to third parties. These data will only be stored and used to process the relevant matter.

By submitting the form, you confirm that you have acknowledged and accepted the Data protection notice.