90325-1310

Please complete this form in block letters using a blue or black pen.
You can also register online at www.zilverenkruis.nl
Application form healthcare insurance
Please continue on the reverse side

1 My details (policyholder)
Initials Suffix Surname
Date of birth

-

-

Male Female Social Security Number
1)


Nationality

Dutch Other
Address House number

Addition

Postal code

Place of residence Country
Home phone number

Mobile number

E-mail address
Are you taking out insurance for yourself? Yes No
Voluntary deductible excess
2)
100.- 200.- 300.- 400.- 500.-
1) We will verify your details against the Municipal administration system. You can find your social security number (burgerservicenummer) on your driving licence, passport or payslip.
2) From 1 January 2014 a mandatory deductible of 360.- applies to each insured person older than 18 years of age. The deductible excess applies to basic insurance only.
You can increase your mandatory deductible excess with a voluntary deductible excess.
2 I wish to take out basic insurance for the following persons
Insured 1 Initials Suffix Surname
Date of birth

-

-

Male Female Social Security Number
1)


Nationality

Dutch Other Relationship to policyholder Partner Child
Voluntary deductible excess
2)
100.- 200.- 300.- 400.- 500.-
Insured 2 Initials Suffix Surname
Date of birth

-

-

Male Female Social Security Number
1)


Nationality

Dutch Other Relationship to policyholder Partner Child
Voluntary deductible excess
2)
100.- 200.- 300.- 400.- 500.-
Insured 3 Initials Suffix Surname
Date of birth

-

-

Male Female Social Security Number
1)


Nationality

Dutch Other Relationship to policyholder Partner Child
Voluntary deductible excess
2)
100.- 200.- 300.- 400.- 500.-
Insured 4 Initials Suffix Surname
Date of birth

-

-

Male Female Social Security Number
1)


Nationality

Dutch Other Relationship to policyholder Partner Child
Voluntary deductible excess
2)
100.- 200.- 300.- 400.- 500.-
3 Participation to group healthcare plan
Name group/company
Group collectivity number

Which family member is member of, works for or receives social benefits from that organisation? (multiple family members possible)


Policyholder

Insured 1

Insured 2

Insured 3

Insured 4
4 Basic insurance Policyholder Insured 1 Insured 2 Insured 3 Insured 4
Beter Af Selectief Polis You can register the Beter Af Selectief Polis only via our website www.zilverenkruis.nl
Beter Af Polis
Beter Af Exclusief Polis
5 Supplementary insurances
Please fill in for persons older than 18 years of age only. You can choose supplementary insurance and/or dental insurance per person.
Persons younger than 18 years of age are insured free of charge for the highest insurance which you or the other parent chooses.
Policyholder Insured 1 Insured 2 Insured 3 Insured 4
Beter Af Plus Polis
b

Beter Af Plus Polis
bb

Beter Af Plus Polis
bbb

Beter Af Plus Polis
bbbb

Beter Af Sport Pakket
3)

Beter Af Fit Pakket
3)

Beter Af Vitaal Pakket
3)

3) Applies to persons older than 18 years of age only. In combination with minimum Beter Af Plus 1
b
only.
2 0 7 0 6 9 1 3 6
Technische Universiteit Delft
5.1 Additional question Beter Af Plus Polis 4
bbbb
(only fill in if you take out this insurance)
Have you or one of the insured persons had more than 20 physiotherapy treatments, manual therapy treatments and/or occupational therapy
treatments (Cesar/Mensendieck) during the past 12 months, or are you expecting more than 20 treatments?
Policyholder Insured 1 Insured 2 Insured 3 Insured 4
Yes No Yes No Yes No Yes No Yes No
6 Dental insurance (only fill in for persons older than 18 years of age)
Policyholder Insured 1 Insured 2 Insured 3 Insured 4
Beter Af Tandarts Polis
b

Beter Af Tandarts Polis
bb

Beter Af Tandarts Polis
bbb

Beter Af Tandarts Polis
bbbb

6.1 Additional question Beter Af Tandarts Polis 2, 3 and 4
bbbb
(only fill in if you take out this insurance)
Has/have the policyholder/insured persons been to the dentist for a check-up during the past 13 months?
Policyholder Insured 1 Insured 2 Insured 3 Insured 4
Yes No Yes No Yes No Yes No Yes No
Does/do the policyholder/insured persons have the most extensive dental insurance with their current healthcare insurer?*
Policyholder Insured 1 Insured 2 Insured 3 Insured 4
Yes No Yes No Yes No Yes No Yes No
* We may need additional information. In that case you will be sent an extra application form.
7 Assessment insurance obligation (only fill in for persons older than 18 years of age)
Policyholder Insured 1 Insured 2 Insured 3 Insured 4
Do you have a personal income? Yes No Yes No Yes No Yes No Yes No
I receive my income from Netherlands Netherlands Netherlands Netherlands Netherlands
Abroad Abroad Abroad Abroad Abroad
Both Both Both Both Both
8 Why are you taking out basic insurance and from which date?
I am transferring from another healthcare insurer from 1 January I wish to be policyholder from
I have group healthcare insurance and switch group plans on I originated from abroad since
New entitlement to healthcare insurance has been established I am uninsured since
I was insured through Menzis COA administration (MCA) Other
Commencement date

-

-

Taking out healthcare insurance you authorise Zilveren Kruis Achmea Zorgverzekeringen N.V. Achmea Zorgverzekeringen N.V. to terminate your
current healthcare insurance including possible supplementary insurances on your behalf. Should you NOT wish us to do so, please tick the box.
I wish to keep my supplementary insurances with my current healthcare insurer.
9 Premium payments and claim reimbursements
Your account number
4)


I will pay the premium per month quarter half year

year
4) Filling in an account number is also necessary to reimburse your claims.
NL10ZZZ302086370000 Zilveren Kruis Achmea Zorgverzekeringen N.V. / Achmea Zorgverzekeringen N.V. debits your insurance premium, deductible excess,
statutory contribution and any other possible claims from your account. By signing this form you authorise us to do so.
10 Signature policyholder
We register the provided personal details. We use these details to register you, to service you better and make sure that others do not misuse
your details. We can also send you information or offer you other Zilveren Kruis products. Our data processing methods are in accordance with
the Data Protection Board (College Bescherming Persoongegevens) rules.
When signing this form you declare that you:
have completed the form truthfully. Should you not do so we will refuse or retroactively terminate the healthcare insurance.
understand that you have to pay premium from the effective date of the insurance policy.
Date

-

-

Signature policyholder
Please send the completed form in the pre-paid envelope to Zilveren Kruis Achmea, Serviceteam Polis,
Antwoordnummer 10290, 2300 VB Leiden. A postage stamp is not required.