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PASSAGE ST-ANTOINE 7 | CP | CH – 1800 VEVEY 1

NOTICE OF CHANGE

T 021 924 87 40 | F 021 924 87 07 COPRE@COPRE.CH | WWW.COPRE.CH

co re LA COLLECTIVE DE PRÉVOYANCE D E P U I S 1 974

Company : Basic plan

Contract n° : Management plan/complementary

Other :

Personal data of the insured Name :

first name :

Date of birth :

AVS N° :

The following change has been announced concerning the insured person

Salary/rate of activity New annual AVS salary from :

CHF

Note : Depending on the salary increase, the insured person will be required to complete a declaration of health.

Rate of activity from :

%

Change of plan Date of change : Plan :

Basic plan

Management plan/complementary

Other :

Change in civil status

married

divorced

widow(er)

bound by a registered partnership

partnership dissolved

If married or bound by a registered partnership, date of marriage/partnership : Date of birth :

First name of spouse/partner :

If divorced or dissolved partnership, date of the divorce/dissolution of the partnership :

Birth First name(s) :

Date(s) of birth :

New address Address :

Retirement Retirement from :

Other reason for change

Place and date :

Notice of change | January 2014

Stamp, signature of employer : 


Notification of change  
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