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. There is a separate form for international students.

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

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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
This information is not compulsory, but it helps us to process your registration more quickly.
Select the option that applies to you. Leave it blank if you’re not sure.
I receive an income from
I am insured abroad
Insured in
Is there anything else you’d like to explain?
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.
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