Form I’m going digital

Do you choose to go digital via the website? Then fill out the form below for each family member.

Personal data
First name*
Last name*
Telephone number
E-mail*
Enter Email Confirm Email

We recommend to use a private e-mail address.
Date of birth*
DD slash MM slash YYYY
Member ID

You can find this on your certificate of affiliation, settlement invoice or any personal communication of us.
Employer
Bank details
IBAN*

This is your bank account number that you will find on your bank card and consists of 16 to 27 characters.
BIC

This is a unique identification code of your bank, which you will find on your bank card.
In the name of*
First name Surname
Hidden
Electronic confirmation
*
- I confirm that my answers are complete and truthful. *
*
- 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, monitoring doctors, etc.). *

Personal data