Register at AZVZ

Registerform

Register at AZVZ

Fill in the Health Insurance application below to register with AZVZ Insurance. Your personal data are handled with strict confidentiality.

Do you prefer to apply by mail? Download the application form (pdf) and send it to AZVZ, Antwoordnummer 46075, 1060 VB Amsterdam.

Register at AZVZ Register Form

Policy holder

Step 1.
Male/Female

Choice of insurance

Step 2.
* Only in combination with Standard package.

Date of entry

Step 3.

Collectivity

Step 4.
Seaman

Payment of contribution

Step 5.
By means of deduction from salary
Direct Debit

Maximum file size: 268.44MB

Authorization

Step 6.
Please Note! lf you don't have the Dutch nationality, please enclose a copy of a valid passport.

Maximum file size: 268.44MB

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

Letter of agreement

Step 7.

Anti spam check

Step 8.