Check of obligation to insure (Zvw)
You have to complete this form if you are staying abroad (temporarily), or if you are living
and/or working abroad. Please fill out this form, even if you are not registered in the Netherlands.
The questions on this form will help us understand your personal situation. We kindly ask you to
answer the questions truthfully and as fully as possible. Based on the data you provide, we will
assess whether we can draw up a IAK Health Care Insurance for you, continue an existing policy,
or must terminate the existing policy. Missing or incorrect information could lead us to mistakenly
terminate your health care insurance policy or not proceed to draw up a policy even if you are entitled
to it. Once you have completed and signed the form, you can send it as an attachment in an email
to [email protected] or by post to: IAK Verzekeringen, Polisadministratie Zorg,
Antwoordnummer 10661, 5600 WB Eindhoven.
1 Personal details
Policyholder’s surname (+ maiden name if applicable)
You can find your insurance number on your
Initials
Surname prefix
Date of birth
Citizen Service Number (BSN)
Insurance number
Telephone
health care policy document or your insurance
card. You can leave the space blank if you
have not yet received this number. The other
Email address
questions should nevertheless be answered.
What is/will be your address abroad?*
register your location in the municipal records.
Street
House number
If you are registered in the Netherlands but
Zip code
* If you are moving abroad, do not forget to
Town
Addition
(not required)
Country
working abroad, you should fill in your Dutch
address in this section.
Address valid date:
Enter your correspondence address below if you wish to receive your mail at another
address.
Street
House number
Zip code
Town
Addition
(not required)
Country
2 Your situation
Why are you living abroad?
* You qualify as a frontier worker if you
live abroad while receiving income from
employment and/or work-related benefits or
allowances in the Netherlands. You also qualify
as a frontier worker if you live in the Netherlands
while receiving income from employment
Frontier worker*
Answer questions 4 and 5.
Sign the form in question 9.
Emigration/relocation
Answer questions 3, 4, and 5.
Sign the form in question 9.
Holiday/world trip
Answer questions 3 and 4.
Sign the form in question 9.
Study/internship
Answer questions 3, 4, and 6.
Sign the form in question 9.
Secondment/ expatriation
Answer questions 3, 4, and 7.
Sign the form in question 9.
Other
Answer questions 3, 4, and 5. Explain your situation
in question 8. Sign the form in question 9.
abroad.
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Together for a perfectly insured future
3 Duration of your stay abroad
* If you are settling abroad permanently,
In which country are you staying are you settling? please do not forget to register your relocation
in the municipal records.
Are you settling abroad permanently?
Yes*
No
If not, how long will you be staying abroad?
From
Please inform IAK Verzekeringen accordingly
To
4Income
if your personal or financial situation changes
during your stay abroad.
After your move abroad, will you receive any personal income from the Netherlands?
Yes
No
Is this income subject to payment of social security contributions in the Netherlands?
Yes
No
Yes
No
Yes
No
After your move abroad, will you receive any personal income from abroad?
Yes
No
Is this income subject to payment of social security
contributions in your country of residence?
Yes
No
Yes
No
Yes
No
If so, what type of income? (Multiple answers possible)
Depending on your situation, the end date of
Income from employment, as of:
Will you perform 25% or more of this work in the country of residence?
Income from self-employment, as of: Will you perform 25% or more of this work in the country of residence?
Income from benefits or allowances, as of: Type of benefits or allowances
When will the benefits or allowances in the Netherlands end?
Income from pension, as of: Other, namely
your employment in the Netherlands/Dutch
income may determine the end date of your
If not, what will be the end date of your employment
in the Netherlands/your Dutch income? health care insurance policy
As of:
If so, what type of income? (Multiple answers possible)
2
Income from employment, as of:
Have you been or will you be employed for three consecutive months or longer?
Income from self-employment, as of: Will you perform 25% or more of this work in the country of residence?
Income from benefits or allowances, as of: Type of benefits or allowances
When will the benefits or allowances end?
Income from pension, as of: Other, namely
As of:
IAK Zorgverzekeringen
5 If you stay abroad for more than one year
*If you stay in one of the EU/EEA countries or
Switzerland, or if you are already covered by
Does the social security legislation of your country of residence require you
to take out insurance in that country?
Yes
No
social insurance arrangements in that, ask you
insurance provider in your country of residence
for an E104 form. Include the E104 form as an
attachment to this form.
If so, when does your insurance commence?
If you have independent living accomodation
in more than one country,
where is your main residence situated?
6 Study/internship
* If you are moving abroad for an internship,
Is your study/internship the only reason for your stay abroad?
Yes
No
please attach a copy of your internship
Do you intend to return to the Netherlands as soon as you have
completed your study/internship?
Yes
No
Yes
No
agreement when you return this form.
The following questions only apply in case of an internship*
Do you or will you receive any remuneration for your internship?
If so, what is the approximate monthly amount?
7 Secondment/expatriation
To which country will you be seconded?
When does your secondment/expatriation commence?
Do you have a secondment agreement (form A1*/E101**)
or a ‘to whom it may concern’ statement?
Yes
No
seconded exclusively to an EU/EEA country
or Switzerland.
Will your family be joining you abroad? Yes
No
*You might be issued form A1 if you are
** You might be issued form E101 if you are
seconded to one of the following countries:
United States, Canada, Chile, Australia, New
Zealand, South Korea, Israel.
Your employer should apply to the Sociale
Verzekeringsbank (SVB, the Dutch social
insurance bank) for these certificates. Please
send us a copy of the certificate.
If so, who will join you?
The entire family
Partner
Other: fill out the details of the insured persons in question.
Insurance number
Date of birth
Child 1
Insurance number
Date of birth
Child 2
Insurance number
Date of birth
Child 3
Insurance number
Date of birth
Child 4
Insurance number
Date of birth
Are you a civil servant on secondment? Yes
No
8 Other information/comments
Do you have other relevant information or comments? Please use the comments field below.
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Together for a perfectly insured future
9 Signature
We are unable to process your application if you do not agree with the general terms and
conditions. You can do so online by ticking the option below and entering the date in
question 9A. If you have printed the form, you can accept by placing your signature and
the date in question 9B.
9A
I accept the general policy terms and conditions
Date
9B
Signature of policyholder:
Date
You confirm that you have answered the questions on this form completely and truthfully and that you
have notified IAK Volmacht B.V. of all the facts about yourself and any other co-insured persons that you
know or should know and that are relevant to this insurance application. You understand that failing to
complete the form truthfully and in full or withholding facts may cause your entitlement to payment to
be restricted or to lapse, or the insurance to be cancelled or refused.
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 B.V. and/or IAK Volmacht B.V. is/are 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 B.V. and/or IAK Volmacht B.V. operate(s) 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 B.V. is an insurance intermediary, responsible for arranging
IAK Health Care Insurance and various supplementary insurance packages. IAK places the administration
of these insurance policies with IAK Volmacht B.V., 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) 261 19 11, F (040) 261 12 05
www.iak.nl
IAK Verzekeringen B.V. Chamber of Commerce: 17086794
IAK Volmacht B.V. Chamber of Commerce: 55688616
AFM licence number: 12007720
IAK Zorgverzekeringen
ZV-TF-ENG (2017)
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