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NOTICE OF CANCELLATION (Desjardins Insurace)

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Desjardins Insurance life health rerement logo
20099E (2020-06)
NOTICE OF CANCELLATION
You have 10 days from when you receive the insurer’s leer of approval to cancel your enrollment in Health Track Insurance
®
and
get a full premium refund. You must complete and return this form to the insurer by the previously menoned deadline.
Aer the deadline, you may end your enrollment at any me, but no premiums will be refunded for the period prior to your
request.
To:
DESJARDINS INSURANCE
Date: (date you’re sending this noce)
I hereby cancel my enrollment in Health Track Insurance.
Member’s name:
Contract number:
Cercate number:
Signed at: Member’s signature:
Please send the original to Desjardins Insurance, C. P. 3000, Lévis (Québec) G6V 9X8
and keep a copy for your records.
NOTICE OF CANCELLATION
Please send the original to Desjardins Insurance C P 3000 Lévis Québec G 6 V 9 X 8
and keep a copy for your records.
C. P. 3000
Lévis (Québec) G6V 9X8
desjardinslifeinsurance.com/planmember
Tel.: 1 877 647-5235
E888
website: desjardins life insurance dot com
slash plan member
Phone number: 1 8 7 7 6 4 7 5 2 3 5
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NOTICE OF CANCELLATION (Desjardins Insurace)

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Completed 9 February 2021

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