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Direct

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Use this form to register for OHRA supplementary insurance
You can also use this form to request OHRA for your current insurance to be cancelled.
Check the boxes to identify your preferences. Record your answers to all questions in block 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
- 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
!dd-mm-yYYYI start date
I Groupplan details
To be compleed if you are eligible for 0 OrolJO r! i<:rollnl
Personnel or member number
SUCSEZ
TU Delft
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 Prefix
no. (if knownl M Gender Date of birth
Unit no.
Country
Citizen's service number
Number
City
Tel. nr. 2
Street
code
Tel. nr. 1
address
Yes, I would eceive and inteE:sting by e-mii
Do you wish to acquire an insurance policy for yourself? No Yes
I Details insured
Initials Prelix Citizen's service number Gender of birth
M
M
M
F M
Ilnsurance
Please use the table below to select the excess and coverage you wish to apply for. If you select the same supplementary
insurance coverage, denal insurance and excess amounts for all other persons, you only need to complete the first line
coverage - { 650, {
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, Supplementary insurance
Please identify the supplementary insurance coverage you wish to apply for in the fable below
Dental insurance None, TandenGaaf 250, TandenGaaf 500, TandenGaaf 750

N

F

c
n

If you opt for the additional 750' OHRA will need a denfisfs statement for the medical assessment. Your dentist will need to complete
and sign this sfafement. We will send the statement to you
Dafe of birth Basic Coverage - Excess
Ohra handling insurances is 0 name af Delta Uoyd insurances ,nc. in -Chamber 01 Commerce 33052073, PC Box 40000 - 6803 GA Arnhem- Riiksweg
Wes 2 - www.ohra.nl-Telephone-number026 4004850 Ohro hondling is mediotor for Ohro Ohro Medicol expenses Inc.
discipline 01 CZ
Dentallnsurance Supplementary Insurance Coverage
I How would you your premium?
1I you seled direcl debil, you aulhorise OHRA to aulomalically deducl al\ paymenls due 10 us from your bank accounl. The account number you provide lor
Ihis purpose musl be in Ihe name of Ihe policyholder.
We also use your accounl 10 make any paymenls due 10 you.
Monlhly
Dired debil
Please provide your bank accounl number
insuronce

Accept giro
Annually
By making this application, 1 hereby authorise OHRA 10 cancel Ihe basic insurance policy and supplemenlary coverage wilh insurance
company. 1 similarly provide such authorisation on behalf 01 all persons identified on this lorm. The cancellalion applies to all persons identilied on this lorm
Who is your current health insurance
Client number
What type 01 policy do you currently hold? Individual Group Abroad Not insured
Did you take out your heallh insurance yoursell lin your own name) or through someone else (e.g. a parent, or your spouse or partner)?
Mysell Through someone else
Do you want OHRA 10 cancel only seleded insurance policies rather Ihan all insurance policies lor everyone? In that case please identify Ihe insurance
policies you want OHRA to cancel and lor whom.
Sumame Date 01 Birth Basic Insurance Supplementary Insurance Dentallnsurance
one persons to be insured income?
Foreign income is defined as income obtained from employment or a foreign social security
No Yes, the lollowing person(s): Date 01 birth
Date 01 birth
I Are 011 ci1i zens?
Date of birth
Date 01 birth
If one or more of the persons 10 be insured does not possess Dutch citizenship, then OHRA will of the 10 card or those
persons originating Irom an EU Country or an EEC counlry. 1I the persons originate from anolher country, we require a copy 01 Iheir residence permit
The required forms should be attached to this form
Yes No, not the lollowing person(s): Dale 01 birth
Nationalily
Date 01 birth
Nationality
I Extemol Reference
Dale 01 birth
Nationality
Date of birth
Nationality
We will verify your details, upon via Exlernal Reference Register (EVR - Extern Verwijzingsregisterl. Any registered Irauds may have
consequences for your supplemenlallnsurance

The undersigned hereby declares to have answered the
above questions accurately, completely and truthlully.
This application forms the basis lor the health insurance
coverage to be provided by OHRA Zorgverzekeringen
NV, Chamber 01 Commerce number 27093766 and any
other supplementary insurance coverage to be provided
by OHRA Ziektekostenverzekeringen NV, Chamber 01
Commerce number 09067645 subjed to the
cable conditions. These NVs are the CZ Groep in
Tilburg. The undersigned hereby declares to be in
agreement with this.
City
Signature of policyholder
Date
If a minor: signalure of legal
representative
sign this form and send it in the postage-paid envelope to:
OHRA An!woordnummer 3346, 6800 ZC Arnhem
The inlormoion provided to OHRA by the policyholder ond Ihe insured personlsl is primorily inended 10 be used by OHRA to ossess the risk 10 be insured. Once the insuronce policy goes inlo effect, Ihe inlor-
motion moy be used lor to implement the insuronce reloed services ond occount monogemenl reloted to the insuronce policy, os well os lor oclivilies oimed ot creoting efficient business
operotions, ensuring the insuronce compony's continuity, prevenling ond counlering lroud ond lulfilling legol obligotions. OHRA moy olso use your personol inlormotion to inlorm you obout other insuronce
plons ond linonciol services. 1I you do not wish 10 receive such inlormotion, pleose complete the lorm ovoiloble 01 www.ohro.nllunder.privacy.l or call +3110126 400 48 48. OHRA provides this healh nsurance
agreement. Dutch law opplies to Any comploins should be submitted to the Executive Boord. 1I you do not ogree with the decision 01 Ihe Executive Boord, you moy submil your comploint to the
Mogisrote or to the Heollh Insuronce Ombudsmon {see Article 16 01 Ihe Generol Conditionsl
- +31(0)26 40
I How would you like to pay your premium?
If you selecl direcl debil, OHRA 10 aUlomalically deducl all paymenls due 10 us from your bank accounl. The accoun number you provide for
Ihis purpose musl be in the name of the policyholder
We also use your account 10 make any paymenls due 10 you.
Monlhly Quarterly Annually
Direct debil Accept giro
provide your
of current
By making Ihis applicalion, 1 hereby aulhorise OHRA 10 cancel Ihe basic insurance policy and supplemenlary coverage insurance
company. 1 similarly provide such aulhorisalion on behalf of all idenlified on Ihis form. The cancellalion applies 10 all persons idenlified on Ihis form.
Who is your currenl heallh insurance
Client number
What type of policy do you currently hold? Individual Group Abroad Not insured
Did you take out your heallh insurance yourself (in your own name) or through someone else (e.g. a parent, or your spouse or partner)?
Myself Through someone else
Do you wanl OHRA to cancel only selecled insurance policies rather than all insurance policies for everyone? In Ihal case please idenlify Ihe insurance
policies you wan OHRA to cancel and for whom
Surname Date 01 Birth Basic Insurance Supplementary Insurance Denlallnsurance
I Does one or more of the persons to be insured foreign income?
Foreign income is defined as income obtained lrom employment or a loreign social securify payment
No Yes, the lollowing person(s}: Date 01 birth
Date of birth
I Are alJ persons to be
Date of birth
Date 01 birth
1I one or more 01 Ihe persons 10 be insured does nol possess Dulch cilizenship, Ihen OHRA will require a copy of the 10 card or Ihose
persons originaling lrom an EU Country or an EEC Irealy counlry. Illhe persons originale Irom anolher we require a copy of Iheir residence permil
The required lorms should be atlached 10 Ihis form.
Yes No, not the lollowing person(s): Date 01 birth
Nationality
Date 01 birlh

I Extemal Reference Register
Date 01 birth
Nationality
Date of birth
Nationality
We will verify your upon registration, via External Reference Register (EVR - Extern Verwijzingsregisler). Any registered frauds may have
consequences for your supplementallnsurance

The undersigned hereby declares to have answered Ihe
above questions accuralely, completely and Iruthlully.
This application lorms the basis lor the health insurance
coverage o be provided by OHRA Zorgverzekeringen
NV, Chamber 01 Commerce number 27093766 and any
other supp)emenary insurance coverage to be provided
by OHRA Ziektekostenverzekeringen NV, Chamber 01
Commerce number 09067645 subjecl to the appli-
cable conditions. These NVs are the CZ Groep in
Tilburg. The undersigned hereby declares to be in
agreement with this.
City
Signature 01 policyholder
Dale
1I a minor: signalure 01 legal
representative
sign this form and send it in the envelope (no requiredl to:
OHRA N.Y., Antwoordnummer 3346, 6800 ZC Arnhem
The intormalion 10 OHRA by Ihe policyholder ond Ihe in5ured personl51 i5 primorily inlended 10 be u5ed by OHRA 10 asse55 Ihe risk 10 be in5ured. Once Ihe in5urance policy goe5 inlo effecl. Ihe inlor-
mation may be used for 10 implemenl fhe insuronce policy and provide related services and Qccounl management reloed 10 Ihe 05 well 05 for octivities oimed at creating efficient business
operalions, ensuring Ihe In5uronce companY'5 conlinuily. prevenling and counlering lraud and lulfilling legol obligolion5. OHRA may al50 u5e your per50nol inlormalion 10 inlorm insuronce
plans and financial 5ervice5. 1I you do nol Wi5h 10 receive 5uch inlormalion. plea5e complele Ihe lorm available 01 www.ohra.nllunder.privacy.l or call +3110126 400 48 48. OHRA provide5 Ihi5 health insurance
agreemenl. Dulch law 10 Any complainl5 should be 5ubmilled 10 Ihe Execulive Boord. If you do nol agree deci5ion 01 Ihe Board. you may your complanl 10 Ihe
or 10 Ihe Health Insurance Ombud5man 15ee 16 01 Ihe General Condilion51