Register at AZVZ

Policy holder

Step 1.

Male/Female

Male

Female

Other

Initials

Last name

Street name

House number

Additional

Postal code

City of residence

Country of residence

Date of birth

Citizen Service Number (BSN)

IBAN

BIC

Phone number

Email address

Nationality

Choice of insurance

Step 2.

Standard package

* Supplementary package AZVZ Comfort

* Supplementary package AZVZ Comfort Extra

* Only in combination with Standard package.

Date of entry

Step 3.

Date

Collectivity

Step 4.

Seaman

Yes

No

Employer (name)

Payment of contribution

Step 5.

By means of deduction from salary

Yes

No

Direct Debit

Yes (Please upload payroll statement or employment contract by select file)

No

Payroll statement or employment contract

Maximum file size: 268.44MB

Authorization

Step 6.

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

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.

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.

Letter of agreement

Step 7.

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

Registerform

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