Travel Insurance

    Please fill in the form below

    (All fields marked with * are required.)

    Initials*(First letter from given name(s))

    InsertsBetween given name and last name like 'Von' or 'The'

    Family name*Last name

    Gender*

    malefemale

    Date of birth*


    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.