Application form for
(supplementary and/or basic) healthcare insurance
Please fill in using block letters
New insurance
Using this form, policyholders
can apply for basic and/or supplementary healthcare insurance
for themselves and/or family
members or add a person to an
existing healthcare insurance
policy.
Citizen Service Number (BSN):
Your BSN can be found on your
identity card.
Add persons to an existing policy
A. Your personal details (policyholder) Are you already insured with us and would you only like to add family members to your policy?
Fill in your client number, name and date of birth and continue to question B.
Initial(s) 1
Prefix(es) Client number Last name
Date of birth Sex
Citizen Service Number (BSN) Male
Street Female
House number Postal code Nationality
NL
Other*
House number extension
City/Town
Telephone number Mobile telephone number
Email address
Are you applying for insurance for yourself? Yes
No
B. Persons to be insured
Are you applying for insurance for your family members?
If no, continue to question C.
Initial(s) 2
* Are any of the persons to
be insured of Swiss nationality
or nationals of an EU or
EEA country? If so, please send
us copies of their passports or
European Identity Cards.
Are any of the persons to be
insured of another nationality?
If so, please send us copies of
their residence permits.
Prefix(es) Sex
Citizen Service Number (BSN) Male
3
Prefix(es) Initial(s) Citizen Service Number (BSN) Prefix(es) Female
NL
Other*
Nationality
NL
Other*
Sex
Citizen Service Number (BSN) Prefix(es) Female
Nationality
NL
Other*
Last name
Sex
Citizen Service Number (BSN) Male
Page 1
Last name
Male
F8250-201410
Nationality
Citizen Service Number (BSN) Prefix(es) Date of birth Date of birth Other*
Male
6
Female
Sex
Initial(s) NL
Last name
Date of birth Initial(s) Sex
Male
5
Female
Nationality
Last name
Date of birth 4
No
Last name
Date of birth Initial(s) Yes
Female
Nationality
NL
Other*
Income includes salary, profit
or other income from labour,
pension or social insurance. If
you have any questions about
your health insurance in
connection with income derived
from abroad, you can find more
information on our website.
C. General information
Do any of the persons to be insured receive income from abroad?
If yes, who? Insured person
1
2
Yes
No
3
4
5
6
D. Group insurance
Are you applying for group insurance?
If no, continue to question E.
Yes
No
Name of employer/organisation
Date of entering into service
* You can request this from your
employer or organisation.
Group number*
Postal code and city/town of employer/organisation
Staff number/member number*
We reserve the right to inquire with your employer or organisation whether you are entitled to group insurance.
You will find more information
about our health insurance
policies on our website.
E. Health Insurance
Which health insurance policy do you wish to take out? Please choose one of the following.
Univé Zorg Vrij policy Univé Zorg
Geregeld policy Univé Zorg
Select policy
Insured person 1 (policyholder)
Insured person 2 Insured person 3 Insured person 4 Insured person 5 Insured person 6 Excess
A mandatory excess of €375 per calendar year applies to each insured person from age 18. In addition to this, you can opt for voluntary
excess.
Would you like to voluntary excess? Yes No
If yes, please choose the voluntary excess you would like to have covered. You will not need to make a choice for persons under age 18.
Insured person 1
€ 475*
€ 575*
If you are applying for a Univé
Zorg Vrij policy or a Univé Zorg
Geregeld policy and also wish
to take out supplementary
insurance, then make your choice
under F1 or F2. If you are
applying for a Univé Zorg Select
policy and also wish to take out
supplementary insurance, then
make your choice under F3.
You will not need to make a
choice for persons under age 18.
They automatically qualify for
the highest supplementary
insurance taken out by their
parents/caregivers.
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€ 775*
Insured person 3
Insured person 4
Insured person 5
Insured person 6
* The compulsory and voluntary excess have been added up.
Insured person 2
€ 675*
€ 875*
F. Supplementary insurance
Would you like to take out supplementary insurance?
Yes No
If no, continue to question H. If yes, please make your choice under F1, F2 or F3.
F1. Supplementary insurance for the Univé Zorg Vrij policy and the Univé Zorg Geregeld policy
Would you like to apply for a supplementary insurance? If so, please select one of the options below.
Univé Extra Zorg polis Univé Extra Zorg polis
Univé Extra Zorg polis
GoedBeter Best
Insured person 1 (policyholder)
Insured person 2 Insured person 3 Insured person 4 Insured person 5 Insured person 6 For the Univé Tand Beter and
Univé Tand Best dental insurance
packages, you are required to
complete a dentist’s statement
for persons aged 8 or older.
Insured persons under age 18
do not pay a premium if the
policyholder is liable to pay the
premium for the supplementary
and/or dental insurance for at
least one insured person.
If both parents and/or caregivers
have taken out Univé Jong
Pakket, Univé Fit & Vrij Pakket or
Univé Vitaal Pakket cover,
children under age 18 will
automatically qualify for Univé
Extra Zorg Beter cover. If one of
the parents and/or caregivers
chooses an Univé Gezin Pakket,
children under age 18 will
automatically qualify for Univé
Gezin Pakket cover.
Children under age 18 with a
Univé Zorg Select policy qualify
for the same supplementary
insurance policy or policies as
the policyholder.
Would you like to apply for a supplementary dental insurance? If so, please select one of the options below.
Univé Tand Goed Pakket Univé Tand Beter Pakket Univé Tand Best Pakket
Insured person 1 (policyholder)
Insured person 2 Insured person 3 Insured person 4 Insured person 5 Insured person 6 F2. Supplementary insurance for the Univé Zorg Vrij policy and the Univé Zorg Geregeld policy
Would you like to apply for a supplementary insurance including dental care? Please choose one of the following.
If you filled in your choice of supplementary insurance under F1, you will not need to fill in anything below.
Univé Jong Pakket
Univé Fit & Vrij Pakket Univé Gezin Pakket
Univé Vitaal Pakket
Insured person 1 (policyholder)
Insured person 2 Insured person 3 Insured person 4 Insured person 5 Insured person 6 F3. Supplementary insurance for the Univé Zorg Select policy
Do you wish to apply for or do you have a Univé Zorg Select policy? Then select your supplementary insurance below.
Univé Fysio 9 Univé Fysio 18 Univé Tand 250 Univé Tand 500 Univé Europa Univé Wereld
Insured person 1 (policyholder)
Insured person 2 Insured person 3 Insured person 4 Insured person 5 Insured person 6 G. Dentist’s statement
Please answer questions 1, 2 and 3 for the persons to be insured if you are applying for an Univé Tand Beter or Univé Tand Best package.
1. Have the insured persons aged 18 or older had their annual
dental check-up in the past two years? Yes
No
If yes, who? Insured person(s): 1
2
3
4
5
6
2. Do any of the persons aged 18 or older to be insured anticipate that they will have to undergo any of the following treatments within
the next two years? Have any of the persons to be insured started on one or more treatments for:
• the replacement of six or more fillings
• two or more crowns
• one or more bridges
• one or more implants
• partial dentures (plate or frame)
• an extensive gum treatment (periodontal care) Yes
No
If yes, who? Insured person(s): 1
2
3. Can the insured persons from age 8 be expected to require
orthodontic treatment over the next two years? Or have the insured
persons from age 8 started with orthodontic treatment?
Yes
No
If yes, who? Insured person(s): 1
2
3
4
5
6
3
4
5
6
Yes
No
We are authorised to contact your dentist to verify the information you have provided.
The ultimate inception date of
the healthcare insurance may
change, depending on the termination date of the old policy or
the date at which we are able to
determine that an obligation to
take out insurance exists.
H. Inception date and termination service
Coverage must commence on
Have any of the persons to be insured already taken out a policy with a Dutch healthcare insurer?
If no, please answer question 2.
1. By applying for one or more of these health insurance policies you entitle us to cancel the old policy or policies of the persons to be
insured. This authorisation also applies to any supplementary insurance policy or policies. Please notify us here if you do not wish us to
cancel any supplementary insurance policies.
Page 3
The supplementary insurance policy or policies should not be cancelled.
2. None of the persons to be insured currently have a policy with a Dutch health insurer. Please tick as appropriate.
Newborn
Adopted
Insured as a member of the armed forces
Has been an acknowledged conscientious objector
The amount to be deducted by
direct debit for excess, personal
contributions and any
erroneous reimbursements is
capped at €220 per month. We
will send you a giro collection
form for amounts above €220.
If we choose to send you a giro
collection form we will not
charge the associated
administrative costs
Originally from a foreign country
Not insured
I. Payment
Are you adding a new person to be insured under your existing policy? If so, you do not need to answer this question. Your premium
payment method will not change.
What is your account number?
IBAN
Without an account number we will not be able to pay your invoices.
Payment method
You can choose from the following payment methods: monthly or annual payment via direct debit or payment by giro collection form.
Payments by direct debit are not subject to any administration charges. If you prefer to pay by giro collection form, you will be charged
€1.50 in administration charges. Indicate your preference below.
Direct debit, monthly payment
Direct debit, annual payment
Giro collection form, monthly payment (plus costs)
SEPA: secure payments
The Single Euro Payments Area
(SEPA) is an area comprising
more than 30 European
countries where all payments
are made in the same secure
and convenient manner.
Giro collection form, annual payment
SEPA direct debit - standing direct debit authorisation
If you opt for direct debit, by signing this form you authorise N.V. Univé Zorg to issue continuous direct debit mandates to your bank. This
authorisation applies to payment of the premium, the excess, personal contributions and the reversal of any erroneous reimbursements. A
direct debit authorisation will also grant your bank a standing authorisation to deduct a specific amount in accordance with Univé Zorg’s
instructions. The authorisation will be valid for the term of the insurance contract and can be extended to after termination of the contract,
if necessary.
If you are not in agreement with a direct debit collection, you can request to have the entry reversed. Please note that you must contact
your bank about this within eight weeks of the debit date. Your bank will be able to inform you about the conditions.
J. Agreement and signature
By signing this form, I declare that the information provided on it is complete and truthful. I declare that I agree with the applicable insurance terms and conditions in the insurance contract. I declare that I agree with the commencement date, cancellation service (section H)
and payment method (section I) as stated on this registration form.
To consult the terms and conditions, go to www.unive.nl. We will be happy to send you a copy on request. A copy of the terms and conditions is also available for inspection at each of our branch offices. Registration takes place after we have established that the persons to be
insured satisfy the requirements of our health insurance policy.
By taking out this insurance policy with N.V. Univé Zorg, the signatory will also become a member of the Coöperatie VGZ U.A., unless he
or she indicates that he or she does not wish to become a member. Coöperatie VGZ U.A. is shareholder of all shares in N.V. Univé Zorg and
represents the interests of its members in the area of health and other insurance. Membership is automatically terminated upon cancellation of the insurance contract or contracts.
Remember to fill in the date
and town/city and to sign the
document.
Please send this form to:
Univé
Postbus 25212
5600 RS Eindhoven
Contact details of N.V.
Unive Zorg
Below are the details of N..V.
Univé Zorg, which is part of
Coöperatie VGZ U.A. (the VGZ
U.A. Cooperative).
The details of this collector are
also featured on your bank
statement.
Unive
Postbus 25212
5600 RS Eindhoven
Collector’s ID
NL64ZZZ371124070000
Page 4
We request to be provided with all relevant personal details when you apply for or wish to amend an insurance policy. We process your
personal data for the following purposes:
• to enter into and perform your insurance policy/policies or financial service;
• to conduct surveys amongst insured persons, care providers and suppliers to ascertain whether the care was indeed provided;
• to conduct surveys amongst insured persons to establish the perceived quality of the care provided;
• for the purpose of statistical analysis;
• to comply with statutory obligations;
• within the framework of the safety and integrity of the financial sector (to prevent and combat fraud);
•if you participate in a group contract: for information exchange with the contracting party of the group agreement for the purpose of
assessing your right to premium discount;
•to exchange data with Coöperatie Univé U.A. for marketing purposes in connection with services and products offered by Coöperatie
Univé U.A. or its associates.
The registration of that data is governed by the Code of Conduct for the Processing of Personal Data by Health Insurers (Gedragscode
Verwerking Persoonsgegevens Zorgverzekeraars). To consult this code, go to www.unive.nl. We may need to consult your personal details
at the Stichting CIS (Netherlands Central Information System Foundation) in the interests of the safety and integrity of the financial sector.
The reason for this is that we wish to eliminate risks and combat fraud. The privacy regulations of the Stichting CIS (see www.stichtingcis.
nl) apply.
By entering into or amending the insurance contract, you grant permission for your personal and other details to be processed for the
purposes as stated above.
Date Town/city
Policyholder’s signature