FLEXMED GLOBAL
REQUEST FOR OFFER
IMPAT TARIFF
* = compulsory

Insured Persons * (Please complete the following details for all persons to be insured)

Family Name First Name Date of Birth Gender
male
female
male
female
male
female
male
female
male
female
from to (YY.MM.DD)

signature of applicant:
Date:
Tel. +(49) 4152 839 404 , Fax +(49) 40 3296 3117, Email: Antrag@ihcc.de