Paymentform

The information given below will be used to confirm your identity and is needed to be able to carry out the payment of your net amount.

IMPORTANT: We require both the online form and the completed discharge/advance payment contract before Vivium can carry out the payment of your net amount.

The information you provide will be treated as confidential. It will not be used for commercial purposes or passed on to third parties.

Gegevens voor de uitkering

Vul uw gegevens in in de velden hieronder en druk daarna op versturen.

Contract number

Surname

First name

National registration number

Account number type?

Belgian bank account number (IBAN) European bank account number (IBAN) outside Belgium Bank account number outside Europe

Account number

BIC

E-mail address

Control number

Type Subject

Text Verification

Uitkeringen

Paymentform