Students Insurance. Complete & affordable insurance package for international students

Insurance
Personal details
General information

Insurance period

Departure / starting date* (dd-mm-yyyy)

Return / termination date* (dd-mm-yyyy)

Country of residence*

Destination country*

Cover requested

Cover*

In case of travelling within EU: Name of Medical Expenses Insurer with your policy number

Please note: when travelling to or from a non-EU country, Basic or Secondary coverage are only available if you have have a basic healthcare insurance that provides coverage for at least 2x the Dutch tariff in the destination country.
Under Basic and Secondary coverage, own risk of the basic healthcare insurance is not included.

Additional coverage

Do you wish your policy to cover you for winter and underwater sports activities as well? (extra premium � 5.00 per 30 days, does not apply to IPS BASIC coverage)

Yes, I want a coverage for winter and underwater sports activities

Yes, I want coverage for tractor risk

Cancellation cover (only for Dutch citizens)

Payment by*

Bank account information

Premium overview

Excluding € 3.50 policy costs

Total

Personal Details insured

Surname*

Initials*

Firstname*

Prefix

Date of birth* (dd-mm-yyyy)

Gender*

MaleFemale

Om verder te gaan moet dit veld ingevuld worden.

Nationality*

In case of IPS Secondary and within EU

Name of Medical Expenses Insurer*

Policy number*

Address in originating country

Street*

Housenumber*

Number additionals

Postal code/zip code*

City*

Telephone number*

Telephone

Cell phone number

You must enter at least one telephone number.

Additional details*

E-mail address*

Are you*

Name of institution where you are registered or employed

Your registration or employee number

Address in destination country

Street

Housenumber

Number additionals

Postal code/zip code

City

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Are you currently receiving medical treatment or have you had any medical treatment in the last six months?

YesNo

Om verder te gaan moet dit veld ingevuld worden.

For which disease were or have you been treated*

Please note that pre-existing conditions are not covered.

Have you ever been refused for an insurance cover, has your insurance ever been cancelled or have special conditions ever been attached to insurance cover for you?

YesNo

Om verder te gaan moet dit veld ingevuld worden.

Please give details*

Is there anything else you wish to state which may be relevant when assessing this application (such as a criminal conviction in the last 8 years of the applicant or the other persons who will be included under this policy)? This includes offences which have brought you into contact with the police or the criminal justice system (such as questioning or prosecution, a decision not to prosecute or fixed penalties)

YesNo

Om verder te gaan moet dit veld ingevuld worden.

Please give details*

I agree to the terms and conditions of this agreement

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