Health care insurance application form

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1 Health care insurance application form for basic insurance and/or supplementary health care packages / health care insurances The IAK Health Care Insurance and supplementary health care packages / health care insurances are governed by the IAK insurance terms and conditions. A copy of said terms and conditions is available on or from Customer Service, tel. +31 (0) Please answer the questions on this form in full. The completed and signed form should be sent to: IAK Verzekeringen, Antwoordnummer 10661, 5600 WB Eindhoven. 1 s details The policyholder is the person who applies for the insurance for himself/herself and/or for others. The policyholder signs the application and is responsible for paying the premium(s). s surname (+ maiden name if applicable) Initials Surname prefix If you are already insured with IAK and wish to add a family member to the policy, You can find your insurance number on your health care policy document or your insurance card. fill in your insurance number here and proceed to section 2. If you wish to apply for IAK Health Care Insurance for yourself, fill in the details below and then proceed to section 2. Marital status Married/registered Cohabiting Single partnership Street House number Additions Zip code Town Country If you do not have nationality, we can only register you if you enclose a copy of your passport or European identity card. If you come from outside the EU or the EER, please also enclose a copy of the front and back of your residence permit and/or the confirmation letter of the IND. Nationality Telephone address Mobile I hereby grant IAK Verzekeringen permission to use my address for news and special offers. We need this number in connection with paying health care insurance claims. Bank account (IBAN) If you have a foreign bank account, please fill in the BIC code below. BIC code 2 Inception date On which date do you wish the IAK Health care insurance coverage to begin? Desired inception date 1 Together for a perfectly insured future

2 * If you apply to IAK for a health care insurance, IAK will arrange the cancellation of your basic insurance and any supplementary insurances with your old health care insurer. NB: If one of the persons to be insured comes from abroad, you are required to complete the form Toetsing verzekeringsplicht Zvw. You can download the form on the website: or request it from Customer Service: +31 (0) Reason for application Are the persons to be insured switching to IAK directly from another health care insurance company? Yes, they are switching from* No, the persons to be have come from abroad had military insurance insured are newly born were uninsured other, namely have been adopted You only need to complete sections 4 and 5 if you are applying for a new insurance. If you wish to add one or more family members to an existing insurance policy, you can skip these sections and go straight on to question 6. 4 Details of employer / organisation IAK Verzekeringen may have made arrangements with your employer or the organisation of which you are a member regarding group insurance. If you wish to become a participant, you should complete this section. The group number is shown on the survey of premiums. For more information, please contact Customer Service: +31 (0) Name of your employer or the organisation of which you are a member Place of business of your employer / organisation Date of commencement of employment / membership Group number It may be that group arrangements have been made regarding the possible payment methods that apply to your health care policy. For more information, please contact our Customer Service: +31 (0) Health care insurance payment method Preferred payment frequency Monthly Quarterly Half yearly Yearly Preferred payment method Payment slip* Accept ** Direct debit * You may be charged for this. ** Go to for more information about Accept . Salary deduction, my salary number is Pension deduction, my pension number is Mandate for recurrent collections, SEPA SEPA: secure payments The Single Euro Payments Area (SEPA) is an area that encompasses over 30 European countries. Within that area, all payments are made safely and without delay using a single uniform method. Only complete this if you intend to pay via direct debit. Date Signature: Place Collection to be carried out by IAK Volmacht B.V., Beukenlaan 70, 5651 CD Eindhoven, Nederland Collector ID: NL49IAK By signing this mandate form, you authorise: - IAK to send recurrent collection instructions to your bank instructing it to debit your account in relation to your insurance payments; - your bank to debit your account regularly in accordance with the instructions it receives from IAK. Before each direct debit transaction is executed, we will inform you of the amount and the collection date. If you are not in agreement with this direct debit, you can request a refund. In that case, you should contact your bank within 8 weeks following the direct debit transaction. Ask your bank about the relevant conditions. 2 IAK Zorgverzekeringen

3 Vul hier de persoonsgegevens in van de te verzekeren personen. 6 Persons to be insured Do you want the policyholder (section 1) to be included on the policy? Yes No * If you do not have a nationality, we can only register you if you enclose a copy of your passport or European identity card. If you come from outside the EU or the EER, please also enclose a copy of the front and back of your residence permit and/or the confirmation letter of the IND. 3

4 Every insured person aged 18 or over is required to pay a statutory mandatory excess of 360 per calendar year. If you wish, you can increase this excess by opting for a voluntary excess. You do not need to make a choice in respect of children under 18 years of age. 7a Basic insurance If you wish to take out the basic insurance, indicate below which voluntary excess you want It may be that group agreements have been made regarding which packages you can select. Consult the survey of premiums for the list of packages from which you can choose. For more information, contact our Customer Service: +31 (0) b Unique supplementary health care packages (toppings) If you want a Unique supplementary health care package, please indicate below which toppings and reimbursements you want. Compact Select your reimbursement (topping) per type of care here* Fysio / Physio Alternatieve zorg OptiekPlan** Alternative & Special Remedies You can combine your supplementary Compleet Pakket with the Geboortezorg (Childbirth Care) topping and/or the Seniorzorg (Senior Care) topping. Go to for details of the reimbursements linked to these toppings. * You must make a choice. If you opt for a reimbursement of 0 then the topping in question will be switched off. Compleet Select your reimbursement (topping) per type of care here* Fysio / Physio Alternatieve zorg Ortho <18 Alternative & Special Remedies ** OptiekPlan (OpticalPlan) is a savings product whereby you save 100 per year for glasses or contact lenses, up to a maximum total savings amount of 300. You can opt either to purchase glasses/contact lenses each year for 100 or to save the money up to a maximum of 300. The OptiekPlan is cancellable annually. *** You can combine your supplementary Compleet Pakket with the Geboortezorg (Childbirth Care) topping and/or the Seniorzorg (Senior Care) topping. Go to for details of the reimbursements linked to these toppings. OptiekPlan** Seniorzorg*** Geboortezorg*** Senior Care Childbirth Care 4

5 Extra Compleet Select your reimbursement (topping) per type of care here* Fysio / Physio Alternatieve zorg OptiekPlan** Alternative & Special Remedies * You must make a choice. If you opt for a reimbursement of 0 then the topping in question will be switched off. ** This option has already been checked because the OptiekPlan is a standard part of the Extra Compleet Pakket. You can select the IAK Jong Pakket if you are aged between 18 and 27. The IAK Comfort Pakket is for people aged 55 and over. 7c Supplementary health care packages If you would prefer a package that is especially tailored to suit this phase of your life, select either the IAK Jong, Jong Incl., Tand or Comfort Pakket below. Jong Jong incl. Tand* Comfort * Under this package, insured persons aged 18 and above qualify for a standard maximum reimbursement of the costs of dental treatment of 250 per year. 7d Supplementary health care insurance(s) If you wish to take out supplementary health care insurance, indicate your choice below. The basic insurance includes limited dental coverage for children under 18. IAK Tandartsverzekering (Dental Care Insurance) If you want to insure your teeth well and determine for yourself the maximum amount to be reimbursed annually. Reimbursement up to a maximum yearly amount of * Medical selection: If you opt for an IAK Tandartsverzekering (Dental Care Insurance) with a reimbursement of 1900 per year, the IAK ZiekenhuisPlusverzekering (HospitalPlusinsurance) or the IAK Huishoudelijke Hulpverzekering (Home Help Insurance), you need to complete a health declaration form. You can download the form from the website: * 5 Together for a perfectly insured future

6 7d Supplementary health care insurance(s) (continuation) IAK ZiekenhuisPlusverzekering (HospitalPlusinsurance)* If you want a better class of care during a stay in hospital. Ja IAK Huishoudelijke Hulpverzekering (Home Help Insurance)* If you want financial help to ensure that everything runs smoothly at home whilst you are in hospital. Maximum reimbursement per day * Medical selection: If you opt for an IAK Tandartsverzekering (Dental Care Insurance) with a reimbursement of 1900 per year, the IAK ZiekenhuisPlusverzekering (HospitalPlusinsurance) or the IAK Huishoudelijke Hulpverzekering (Home Help Insurance), you need to complete a health declaration form. You can download the form from the website: 8 General Have you, the policyholder, or one of the persons to be insured been refused insurance at any time in the last 5 years? Or has an insurer cancelled your insurance? Yes No If so, which insurer? When, and what was the reason? 6 IAK Zorgverzekeringen

7 9 Comments Please use the space below for any comments you wish to make. 10 Signature By signing this form, you, the policyholder, declare that you wish to take out this/these insurance(s). You also declare that you agree to the application of the relevant insurance terms and conditions. Said terms and conditions are available for inspection at our offices and can be found on the website We can also send you a copy at your request. This application form will form the basis for the health care insurance you are about to take out via the broker IAK Verzekeringen with IAK Volmacht B.V., authorised underwriting agent of the insurer(s). The undersigned declares that he/she has answered the questions on this form fully and truthfully and has passed on to IAK Verzekeringen all the information about himself/herself and any other persons to be co-insured that is relevant to the insurance (including criminal acts in the last eight years) and of which he/she is aware or should be aware. The undersigned is aware that filling in this form incorrectly or incompletely or concealing facts may lead to the entitlement to payment being reduced or cancelled or the insurance being cancelled altogether. Date Signature of policyholder: When you apply for or modify an insurance policy or financial agreement, we ask you for personal and other details. We use these details: to enter into and execute your insurance contract or financial service for the management of relationships arising therefrom for activities aimed at increasing the customer database to investigate whether the care has actually been provided to insured persons to check how the insured parties rate the quality of the care they have received for statistical analysis to comply with statutory requirements to safeguard the security and integrity of the financial sector IAK Verzekeringen is authorised to check the information you have supplied with Stichting CIS in Zeist, for risk management and fraud prevention purposes. In first instance, IAK Verzekeringen uses your information to complete the acceptance procedure. Once the insurance contract has been concluded, we process your details in the interests of efficient and effective operations. IAK Verzekeringen operates in compliance with the Gedragscode verwerking persoonsgegevens Financiële Instellingen (Code of Conduct for the Processing of Personal Data by Financial Institutions). Health care insurers are also required to comply with the Gedragscode verwerking persoonsgegevens Zorgverzekeraars (Code of Conduct for the Processing of Personal Data by Health Care Insurers). IAK Verzekeringen offers IAK Health Care Insurance and various supplementary insurance packages. IAK places the administration of these insurance policies with IAK Volmacht, authorised underwriting agent of the insurers named on the policy schedule. IAK Verzekeringen B.V. IAK Volmacht B.V. Postbus 90165, 5600 RV Eindhoven Beukenlaan 70, Eindhoven T (040) , F (040) IAK Verzekeringen B.V. Chamber of Commerce: IAK Volmacht B.V. Chamber of Commerce: AFM licence number: ZV-AF-UNIEK VGZ -ENG( ) 7

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