You are affiliated with CM as a dependent

Do you want to join in your own name (as a 'gerechtigde'), for example because you are starting to work?

Are you a CM member, registered as a dependent (persoon ten laste)? To join as a beneficiary (gerechtigde), for example, because you're starting work, please complete the application below. We will contact you as soon as possible to arrange your registration as a beneficiary.

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Identification

First name

Last name

Marital status

Nationality

National Register Number

Principal residence

Street

House number

Bus

Country

Postal code

City or municipality

Phone/mobile

Email address

Change of status

Reason for change of status

I have been working as an employee (bediende) since:

I have been working as an employee (arbeider) since:

I have been working as a self-employed person since:

I am unemployed and entitled to a reintegration benefit (inschakelingsuitkering) from/since

Other…

Since (date)

Other information

Would you like to receive information about additional CM insurance policies without obligation?

Reimbursement for hospitalization

Reimbursement of medical expenses without hospitalization

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