Contract and time
Please answer the following questions about your contract, date settings and desired insurance coverage.
Advisor: International Insurance, Postbus 150, 2810 AD Reeuwijk.
Contract number: 3525
Please complete the following questionnaire. Accurately fill in your name as it should appear on your policy as well as gender and Date of Birth, and address including house number. If you don’t know your Dutch address yet, please use the address of our office (Postbus 150, 2810 AD Reeuwijk).
To complete your request, please leave your contact information along with your bank account number. By clicking 'submit' you accept that your account number will be used for the payment of your insurance by direct debit.
In order to complete your request please provide your financial account information. By Clicking “Submit” you acknowledge this will be the primary account the payment will be debited from.
Choice of payment*: direct debit.
A A Dutch IBAN number is required to set up your account. If you do not yet have a Dutch IBAN please let the field blank. We will send to you a payment link.
PLEASE NOTE! You don’t have to pay in advance. You can pay within one month after your arrival in the Netherlands.
By submitting this form you are applying for a travel insurance.