Health Insurance for Foreigners – Insurance Contract Cancellation

1Insurance policy / Insured

2Overpayment

POLICYHOLDER'S NAME AND SURNAME *

Křestní jméno

Druhé jméno

Příjmení

INSURED'S IDENTITY CARD OR PASSPORT NUMBER *

TELEPHONE NO *

EMAIL *

POLICY NUMBER *

12 digits that can be found, for example, on the health insurance card that we sent you when arranging insurance.

HEREBY I REQUEST TO CANCEL THE INSURANCE POLICY DUE TO *

End of the insured's stay in the Czech Republic
Rejection of the application for a visa to stay in the territory of the Czech Republic
Transition to Public Health Insurance
Replacement of the contract with a new insurance contract No.
Other reason