Verdragspolis registration

Use this form to register for the Verdragspolis. The Verdragspolis covers medical care both in the Netherlands and in the country in which you are insured (through your health insurance in that country).

This form contains errors. Check the fields and send again.

If so, ask the Sociale verzekeringsbank (SVB) for a 'Wlz assessment'. This can be done via the website of the SVB (www.svb.nl), or via telephone number +31 (0)20 656 48 48.

Your package

The 'Jongeren' and 'Gezinnen' additional insurance packages already include dental insurance. If you have either of these packages, you will not need to take out separate dental insurance.
Take advantage of a discount on the premium and more extensive reimbursements. If you have received a group insurance number from your employer or member organisation, please enter it here. Please note: the discount is given only on the premium for an additional insurance package, because you do not have to pay a premium for the 'Verdragspolis'.
dd-mm-yyyy
Your customer number is displayed on your CZ healthcare card or policy.
dd-mm-yyyy
House number and suffix
If you are not an EU/EEA national, we need a copy of the front and back of your residence permit.
We will cancel your current health insurance for you from the date you are registered in the Verdragspolis. We do this because we are obliged to provide your current health insurer with information that is necessary for the implementation of the health insurance and the Dutch Healthcare Insurance Act. This also applies to registered family members.
We will send confirmation to this email address.
We are sometimes able to help you faster if we call you.
House number and suffix
Only for addresses outside of the Netherlands.

Partner

Your partner’s package

The 'Jongeren' and 'Gezinnen' additional insurance packages already include dental insurance. If you have either of these packages, you will not need to take out separate dental insurance.
Your customer number is displayed on your CZ healthcare card or policy.
dd-mm-yyyy
House number and suffix
If your partner is not an EU/EEA national, we need a copy of the front and back of his/her residence permit.
If so, we will cancel the current health insurance from the date your partner is registered in the Verdragspolis.

Children

Your customer number is displayed on your CZ healthcare card or policy.
dd-mm-yyyy
If your child is not an EU/EEA national, we need a copy of the front and back of his/her residence permit.
If so, we will cancel the current health insurance from the date your child is registered in the Verdragspolis.
Your customer number is displayed on your CZ healthcare card or policy.
dd-mm-yyyy
If so, we will cancel the current health insurance from the date your child is registered in the Verdragspolis.
Your customer number is displayed on your CZ healthcare card or policy.
dd-mm-yyyy
If so, we will cancel the current health insurance from the date your child is registered in the Verdragspolis.
Your customer number is displayed on your CZ healthcare card or policy.
dd-mm-yyyy
If so, we will cancel the current health insurance from the date your child is registered in the Verdragspolis.
Your customer number is displayed on your CZ healthcare card or policy.
dd-mm-yyyy
If so, we will cancel the current health insurance from the date your child is registered in the Verdragspolis.
Only enter a BIC if your bank account is not a Dutch bank account

If so: Please also send us a copy of your valid passport. Via email to verdragspolis@cz.nl or via post to CZ, Postbus 90152, 5000 LD Tilburg.

Signature

Before you sign, we would like to point out the following: (1) We can only process your registration for the ‘Verdragspolis’ once we have received your E106/S1/E121 form issued by your foreign health insurer (2) We will check your details against the External Reference Register (‘Extern Verwijzingsregister’). An entry in this fraud register may affect your additional insurance package.