Agent

    Applicant

    Emergency Contact

    (for couples taking out a plan each please submit 2 separate applications)

    Second Person

    Emergency Contact

    Plan

    Bronze Plan 2595€--2595Silver Plan 2995€--2995Gold Plan 3995€--3995Repatriation Plan 7995€--7995

    FullMonthly Instalments

    Direct Debit

    By signing this mandate form for your White Doves Funeral Plan, you authorise (A) Grupo MCortexx SL to send instruction to debit your account and (b) your bank to debit your account in accordance with the instruction from Grupo MCortexx SL. You are entitled to a refund from your bank after your account has been debited and you can request your bank not to debit your account up until the day on which the payment is due. Please contact your bank for detailed procedures in such a case.

    YOUR DECLARATION