You are not affiliated with any health insurance fund

You want to join CM in your own name (as titleholder).

You have never been affiliated with a health insurance fund, not even as a dependent? Please complete the application below and forward it.

We will contact you as soon as possible to arrange your registration.

Identification
Sex
Are there other family members who will join (partner, child)?
Write down their full name, Belgian national register number and status. Provide some explanation if necessary.
Main residence
Other data
I receive an income from
I am insured abroad
Insured in
If you would like to add a document to complete your registration, you can do so here.
One file only. 10 MB limit. Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.