Télécharger la plaquette R Dynamique 2016

Télécharger la plaquette R Dynamique 2016

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Mutuelle soumise aux dispositions du livre II du Code de la Mutualité • Mutuelle fondée le 15 février 1905 • Numéro d’immatriculation au Registre National des Mutuelles 776 398 786 • N° SIRET 776 398 786 00025 •
CCPC LYON 1067 - 62 U. Juillet 2015 / « Copyright © 2015, MIEL Mutuelle Micro Application et ses concédants. Tous droits réservés. » « Conception & réalisation : Service communication MIEL Mutuelle » • Document
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Bulletin d’affiliation
Votre conseiller commercial :
ou code courtier
Vos Informations Personnelles
Vous : Civilité :
M
Mme
Mlle
Nom : ..........................................................
Nom Patronymique : .........................................................
Prénom : .....................................................
Date de naissance : .........................................................
Votre numéro à votre organisme social :
N° d’organisme d’affiliation (figurant sur votre attestation vitale) :
Complément nom : ............................................
Complément Voie : ............................................................
N° et libellé de la voie : ........................................................................
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Email : ............................................@......................
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Profession et Catégorie Socioprofessionelle (cocher celle qui vous correspond) :
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• Je choisis le niveau de garanties : R Dynam
R Dynam 1
R Dynam 2
R Dynam 5
• Je dépends du : Régime général
R Dynam 3
R Dynam 4
R Dynam 6
Régime Alsace Moselle
• Je souhaite être affilié(e) à compter du 01/
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Vos ayant(s) Droit
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• Enfants et / ou personnes à charge (joindre le justificatif de situation / liste page 4 de ce bulletin) :
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11 rue du Gris de Lin - 42021 SAINT-ETIENNE CEDEX 1 • Tél. : 04 77 49 35 35 - Fax : 04 77 49 35 48 • www.mielmut.fr • [email protected]
Mutuelle soumise aux dispositions du livre II du Code de la Mutualité • Mutuelle fondée le 15 février 1905 • Numéro d’immatriculation au Registre National des Mutuelles 776 398 786 • N° SIRET 776 398 786 00025 •
CCPC LYON 1067 - 62 U. Juillet 2015 / « Copyright © 2015, MIEL Mutuelle Micro Application et ses concédants. Tous droits réservés. » « Conception & réalisation : Service communication MIEL Mutuelle » • Document
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Mutuelle soumise aux dispositions du livre II du Code de la Mutualité • Mutuelle fondée le 15 février 1905 • Numéro d’immatriculation au Registre National des Mutuelles 776 398 786 • N° SIRET 776 398 786 00025 •
CCPC LYON 1067 - 62 U. Juillet 2015 / « Copyright © 2015, MIEL Mutuelle Micro Application et ses concédants. Tous droits réservés. » « Conception & réalisation : Service communication MIEL Mutuelle » • Document
contractuel.
PIECES A RETOURNER OBLIGATOIREMENT A MIEL MUTUELLE
□ Bulletin d’affiliation dûment complété
□ Relevé d’identité bancaire, postal ou caisse d’épargne
□ Mandat de prélèvement SEPA
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Pour l’affilié et chaque ayant-droit déclaré au contrat :
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Carte Vitale
Pour le conjoint si le nom de famille diffère :
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Pour les enfants âgés entre 20 et 25 ans :
□ Dernier avis d’imposition ou certificat de scolarité de l’année en cours.
Pour les autres personnes à charge se référer au règlement mutualiste.
11 rue du Gris de Lin - 42021 SAINT-ETIENNE CEDEX 1 • Tél. : 04 77 49 35 35 - Fax : 04 77 49 35 48 • www.mielmut.fr • [email protected]
Mutuelle soumise aux dispositions du livre II du Code de la Mutualité • Mutuelle fondée le 15 février 1905 • Numéro d’immatriculation au Registre National des Mutuelles 776 398 786 • N° SIRET 776 398 786 00025 •
CCPC LYON 1067 - 62 U. Juillet 2015 / « Copyright © 2015, MIEL Mutuelle Micro Application et ses concédants. Tous droits réservés. » « Conception & réalisation : Service communication MIEL Mutuelle » • Document
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contractuel.
MANDAT de Prélèvement SEPA
A retourner à : MIEL Mutuelle, 11 rue du Gris de Lin 42021 Saint-Etienne Cedex 1
En signant ce formulaire de mandat SEPA (Single Euro Payments Area), vous autorisez MIEL Mutuelle à envoyer des instructions
à votre banque pour débiter votre compte, et votre banque à débiter votre compte conformément aux instructions de MIEL
Mutuelle.
Vous bénéficiez du droit d’être remboursé par votre banque selon les conditions décrites dans la convention que vous avez
passée avec elle.
Une demande de remboursement doit être présentée :
- dans les 8 semaines suivant la date de débit de votre compte pour un prélèvement autorisé,
- sans tarder et au plus tard dans les 13 mois en cas de prélèvement non autorisé.
Votre nom
MIEL Mutuelle
FR72ZZZ391079
11 rue du Gris de Lin
42021 Saint-Etienne Cedex 1
FRANCE
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Date : JJ/MM/AAAA
Signature(s)
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