Submission of costs

You can submit your medical costs via this online form. Fields with an asterisk (*) are mandatory.
  • We recommend to use a private e-mail address.
  • Date Format: DD slash MM slash YYYY
  • This is your bank account number that you will find on your bank card and consists of 8 to 11 characters.
  • This is a unique identification code of your bank, which you will find on your bank card.
  • Drop files here or
    Attention: Total size of uploaded files is limited to 8 MB.

    Please be sure to keep the original of the (scanned) copy and immediately make it available to Vanbreda Risk & Benefits if so requested. You hereby confirm that you will only request the reimbursement of these costs via Vanbreda Risk & Benefits and will immediately inform Vanbreda Risk & Benefits if you receive a reimbursement of these costs in any other way. In that case you are not entitled to a reimbursement via Vanbreda Risk & Benefits.