Affiliation form STIB/MIVB

Hidden

Client ID*

This number consists of 6 digits

Your employer offers a hospitalisation insurance for you and your family members.

Please fill in the form below to affiliate to this insurance for yourself and your family members.

Please note: when we process your request, we will check which policies you are entitled to via your employer and affiliate you. We will send you an insurance certificate as confirmation of your affiliation.

Your employer STIB/MIVB offers a hospitalisation insurance for you and your family members.

As an employee, you automatically affiliate one year after the date of your commencement of employment.

If you want to affiliate earlier (within the first year after your commencement of employment), you can do so on voluntary basis, with personal payment of the premium. Attention: in that case, you must apply for affiliation within 3 months after your commencement of employment.

Your family members can affiliate as soon as you are affiliated

Fill in the form below to affiliate yourself and/or your family members.

You can find the policy conditions here.

Employee

First name of employee*

Last name of employee*

Date of birth of employee*

Member ID

You can find this on your insurance certificate, settlement note or any personal communication. of us

Rijksregisternummer*

Geslacht*

V
M

Your details

Werkboeknummer

Personeelsnummer

Street*

Number*

Box

ZIP code*

City*

Country*

Language*

E-mail*

Enter e-mail Confirm e-mail

We recommend to use a private e-mail address.

Phone number

Hidden

CategorieVerzekerde

Guarantee

Employer*

Date of employment*

Affiliate to*

Hospitalisation Plan
Outpatient Plan

Waarborg CEPA

Jouw keuze*

Tarief en toepassing van je verzekering vindt u in bij de veelgestelde vragen hieronder.

Hidden

Datum onderschrijving

Datum in dienst

Hidden

Datum aansluiting*

Hidden

Wedde*

Hidden

% TWST*

Hidden

Toestand*

Was je reeds verzekerd op de polis Gewaarborgd Inkomen van CEPA vóór 01/09/2020?*

Ja
Nee

Waarborg Verenigde Ziekenhuizen van Waas & Durme

Date of employment

Jouw keuze*

Ik wens mij uit te schrijven voor deze facultatieve bijkomende verzekering gewaarborgd inkomen en behoud enkel het basisplan. Ik heb goed begrepen dat later opnieuw aansluiten niet mogelijk is.
Ik wens mij in te schrijven voor de facultatieve bijkomende verzekering gewaarborgd inkomen, bovenop het basisplan.

Was je reeds aangesloten op de facultatief bijkomende verzekering?*

Ja
Nee

Who would you like to affiliate?

The following family members can affiliate:

Partner: cohabiting partner or husband / wife
Children: children entitled to family allowance

If you wish to affiliate family members to the hospitalisation insurance, you have to affiliate each member of your family, except those who are already affiliated to a similar insurance.

You can affiliate co-insured persons (your partner and your children) to your medical plan as soon as they are entitled to it. This is at the earliest the day on which your own affiliation as main insured person starts. You have three months after the first day on which they can be affiliated to submit the application in time.

Do you submit your application after this three-month period? Then we call this a late affiliation. In that case, you have to take a waiting period of twelve months into account.

Which family members do you want to affiliate?

My partner
My child(ren)

Family situation*

My partner has his / her own insurance
I don't have a partner

Details Partner

Name	First name	Actions
		Edit Delete
There are no Partners.

Maximum number of partners reached.

Why would you like to affiliate your partner?*

Employed main insured person
Living together / married
Terminate similar insurance

Date of employment of the principal insured person*

Since what date have you been cohabiting / married?*

Date of termination of similar insurance?*

Affiliate to*

Hospitalisation Plan
Outpatient Plan

Affiliate to*

Hospi
Hospi Plus
Hospi Top

Consult the policy conditions of the various guarantees via the link at the top.
All family members must affiliate to the same policy.

Details child(ren)

Name	First name	Actions
		Edit Delete
There are no Children.

Maximum number of children reached.

Why would you like to affiliate your child(ren)?*

Employed main insured person
Birth / adoption / custody of child / foster child / other
Terminate similar insurance

Date of employment of the principal insured person*

Since which date has this child become part of the family?*

Date of termination of similar insurance?*

Affiliate to*

Hospitalisation Plan
Outpatient Plan

Affiliate to*

Hospi
Hospi Plus
Hospi Top

Consult the policy conditions of the various guarantees via the link at the top.
All family members must affiliate to the same policy.

Confirmation

I confirm that my answers are complete and truthful.*

Ik bevestig dat ik vandaag 100% arbeidsgeschikt ben. *

I agree to Vanbreda Risks & Benefits's privacy policy and the rights listed in the policy that I as a data subject can exercise, and to the General Terms and Conditions of Health Care Digital and AssurMiFID code of conduct. This data, including my health data, may be processed by Vanbreda Risk & Benefits for the purposes of customer service, accepting risks, managing contracts and claims, making insurance related payments, and the proper functioning of their services. If it is required to execute this agreement or if they obliged to do so by law, Vanbreda Risk & Benefits may forward my personal data to third parties (insurers, experts, medical officersmonitoring doctors, etc.). *