(All fields marked with * are required.)
Initials*(First letter from given name(s))
Inserts Between given name and last name like 'Von' or 'The'
Family name* Last name
Gender*
malefemale
Date of birth*
Select day12345678910111213141516171819202122232425262728293031Select month010203040506070809101112
Address details
When you already know your address in the Netherlands, please fill in your address. If you don’t know your address yet, please use our address. Postbus 150 2810 AD Reeuwijk
Street name in the Netherlands*
House number in the Netherlands* For example 105 or 1B, not your phone number*
Postcode in the Netherlands*
City in the Netherlands*
Insurance specifics & coverage details
Starting date* (this is the day you will leave your country, also the coverage for your insurance will start on this day).
Coverage
Worldwide excluding USA
If you want worldwide including USA coverage, please send us an email. (You can add USA coverage during your stay in the USA. For this you pay more premium per month. The amount you pay more is € 26,60 per month).
Contact information
Email address*
Phone number including country code*
Payment details
PLEASE NOTE! No advanced payment is needed. You can pay within one month after your arrival in The Netherlands. The insurance company OOM Verzekeringen will send to you a payment link via e-mail. Payment by credit card is possible using that link.
By submitting this form you are applying for a private travel insurance for 30 days € 58,27 fixed-price.
