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| DIRECT DEBIT INSTRUCTIONS | ||||||||||||||||||
| Please write the full name and address of your bank or building society. | ||||||||||||||||||
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| Account Number: | ||||||||||||||||||
| Bank sort code: | ||||||||||||||||||
| Monthly | Annually | |||||||||||||||||
A Credit charge applies if paying by instalments Note: Direct Debits are collected the first working week of each month. |
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Declaration I/we instruct you to pay direct debits from my/our account at therequest of QUINN-healthcare. The amounts are variable and may be debited on various dates. I/we understand that QUINN-healthcare may change the amounts and dates only after giving prior notice. I/we will inform the bank /building society in writing if I /we wish to cancel this instruction. I/we understand that if any direct debit is paid which breaks the terms of this instruction, the bank/building society will make a refund. |
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| QUINN-healthcare membership number. | ||||||||||||||||||
| QUINN-healthcare Limited identification number: 301467 | ||||||||||||||||||
(Banks and building societies may refuse to accept instructions to pay direct debits from sometypes of account.) Your insurance is provided by Quinn Insurance Limited. Quinn Insurance Limited (trading as Quinn Healthcare) is regulated by the Financial Regulator. |
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