Public health insurance Policy

No risk Public health insurance Policy

For expats/internationals, and their partners, that are (self-) employed in The Netherlands.

More info

Private student health insurance policy

For non-working international students that are enrolled at a Dutch university.

More info

Private temporary health insurance policy

For people that neither work nor study in The Netherlands

More info

A list with highlights

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Register

"*" indicates required fields

Your form has been sent and you can fill in the form again for another family member.

PARTICULARS POLICYHOLDER

Surname/Family name*

Given name*

Date of birth*

Gender*

Male

Female

BSN*

Phone (where we can reach you during office hours)*

Email address*

Marital status*

Single

Married

Living together

No Risk III Supplement (EUR 13,75- pm in 2024)*

Yes

Nationality*

Effective date (as from which date do you want the new insurance to start)*

ADDRESS DETAILS

Address*

Street Address House No. ZIP / Postal Code City of residence Country

BANK ACCOUNT DETAILS

IBAN (Account)

Account holder's name*

By signing this mandate form, you authorise LoonZorg B.V. to send recurrent collection instructions to your bank to debit your account concerning the monthly premium and your bank to debit your account on a recurrent basis in accordance with the instructions from LoonZorg B.V. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Ask your bank for the conditions.

Date*

Please print your full name*

How did you first hear about LoonZorg*

By sending this form to LoonZorg B.V., applicant authorizes LoonZorg B.V. to register the person stated above for the HollandZorg public health insurance. The policy will be effective after receipt of the first monthly premium. This application is only valid after receipt of the requested documents. LoonZorg has the right to end the insurance as from the date the insured stopped working for current employer. LoonZorg will only use your personal details for policy purposes and will not share these details with third parties. For more information please find following privacy statement

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