You are not affiliated with any health insurance fund

You have never been affiliated with a health insurance fund, not even as a dependent? Please complete the application below and forward it. There is a separate form for international students.

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

Identification

First name

Last name

Sex

male

female

Marital status

Nationality

Belgian National Insurance Number

Date of birth

Are there other family members who will join (partner, child)?

yes

no

Other family members

Write down their full name, Belgian national register number and status. Provide some explanation if necessary.

Main residence

Street

House number

Letterbox

Country

Postal Code

City or municipality

(Mobile) phone

E-mail address