飞 U l I D 1 . Direct 飞 J l l n l l r \ v r 飞 g e 陀 g e l d P t l í l l 川 酬 1 Use this form to register for OHRA Z o r g v e r z e k e r i n g α n d supplementary insurance c o v e r α g e . You can also use this form to request OHRA t o α r r a n g e for your current insurance to be cancel led. Check the boxes to identify your preferences. Record your answers to all questions in block l e 忖 e r s using a blue or black ink ballpoint pen You are eligible for OHRA insurance if you meet at least one of the following conditions - You live in the Netherlands - You work in the Netherlands employment c o n t r a c 叫 - You pay income tax in the Netherlands The start date 01 your insurance is 1 January of any given year. Exceptions are noted in the General Conditions. You may change your health insurer each y e α 「 dd-mm-yYYYI 仔 e c t i v e start date I Groupplan details To be comple • ed if you are eligible for 0 OrolJO r i<:rollnl Personnel or member number SU SEZ TU elft Col l. 219 Group plan contract number Name of group plan I Policyholder details The policyholder is • he person applying for • he insurance Initials Sumame refix i e n t no. (i f knownl ender ate of birth Unit no. Country Citizen's service number Number City Te l. nr. Street P o s t α 1 code Te l. nr. 1 E m α i l address Yes , I would l i k ε t o ïeceive ~ 阳 、 i n f o r m a t i o n and inteï E: sting 0 仔 e r s by e-müii Do you wish to acquire an insurance policy for yoursel f? N o es I Details o f 。 伽 e r persons 协 e insured Initials Prelix Ci tizen's service number ender α t e of birth u r n a π 1 e M M M F Ilnsurance e 怕 s Please use the table below to select the excess and s u p p l e r n e n t a i n s u r a n c e coverage you wish to apply for. If you select the same supplementary insurance coverage , den • al insurance and excess amounts for all other persons , you only need to complete the first line B α s i c coverage - E x c e s s 在 4 5 0 ， 仨 5 5 0 ， { 650 , { 7 5 0 ， 仨 8 5 0 The excess is the amount thaf you pay yoursell each year if you incur any healthcare costs. The higher the excess , the lower the premium. For insured persons aged 18 and over a mandatory excess of E 350 applies. If you wish to apply for a higher excess , please select the appropriate amount in fhe table below. The options selected are inclusive of fhe mandafory E 350 excess. There is no excess lor supplemenfary insurance coverage and dental insurance. None , Aanvullend , Extra aanvullend , Uitgebreid , Extra Uitgebreid , upplementary insurance o v e r α g e Please identify the supplementary insurance coverage you wish to apply for in the fable below ental insurance None , TandenGa af 250 , TandenGa af 5 00 , TandenGaaf 750 ∞ 的 N F 的 。 口 的 由 叶 If you opt for the additional i n s u r a n c e 寸 a n d e n g a a f 750' OHRA will need a denfisfs statement for the medical assessmen t. Your dentist will need to complete and sign this sfafemen t. We will send the statement to you Dafe of birth Basic Coverage - Excess Ohra handling insurances is 0 r 口 J e name af Delta Uoyd h 口 n d l i n g insurances , n c. in A m s l e r d 口 -Chamber 01 Commerce 33052073 , PC Box 40000 6803 GA Arnhem- Riiksweg Wes • 2 - www.ohra . nl-Telephone-number026 4004850 Ohro hondling i n s u r 口 n c e s is mediotor for Ohro H e 口 I t h i n s u r o n c e s n c 口 n d Ohro Medicol expenses i n s u r 口 n c e s Inc. b o t h 口 discipline 01 CZ Dentallnsurance upplementary Insurance Coverage
