Stichting Scheepvaart | Health Insurance form AZVZ

1. Policy holder

Male/Female *

Male

Female

Initials *

Last name *

Date of Birth *

Address *

Postal code *

City of residence *

Country of residence *

Nationality *

Citizen Service Number (BSN)

IBAN *

BIC

Mobile phone

Telephone

E-mail Address

2. Choice of insurance

* Standard package

* Supplementary package AZVZ Comfort

* Supplementary package AZVZ Comfort Extra

* Only in combination with Standard package.

3. Date of entry

Date *

4. Collectivity

Seaman *

Yes

Employer (name) *

5. Payment of contribution

By means of deduction from salary *

Yes

Direct Debit *

Yes

6. Authorization

AZVZ is authorized to terminate my current health insurance in The Netherlands

Please Note! lf you don't have the Dutch nationality, please enclose a copy of a valid passport.

Copy of Passport

lf you are a resident of a Member State of the European Economic Area, on request we will send you an E106 European form.
E 106: Certificate of entitlement to sickness and maternity insurance benefits for persons residing in a country other than the competent country. With this form you and your family members can register at the health insurance authorities in your country of residence.

Please sent me an E-106 European form

With this form you and your family members can register at the health insurance authorities in your country of residence.

7. Letter of agreement

* I, the undersigned, declare the information I have provided for this application is true and complete to the best of my knowledge and believe.

* I, the undersigned am aware that any incorrect information provided or any information of interest to the insurer withheld, can be of consequence to the validity of the insurance.

Date of submission *

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