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Place Date:  
Subject: Cancellation of insurance with OOM
Policynumber: 
Dear madam, sir,
I hereby inform you that I wish to terminate the above insurance as of .
If the stated date is not correct, I request that you use the correct contract expiry date. This cancellation will then take effect on that date.
I request that you confirm this cancellation,
Yours sincerely,
Signature: 
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Account number for possible OOM premium refund: 

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Laan van Nieuw Oost-Indië 133L
2593 BM Den Haag
P.O. Box 97640
2509 GA Lahey
Hollanda

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T. +31 70-2051860
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E. info@insuretostudy.com
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