Insurance benefit declaration in the Netherlands

Tax year

Attention ! the benefits year is the year for which you file your Insurance benefits.

The beneficiary's personal data

Attention ! valid date format: day-month-year
Attention ! BSN - burgerservicenummer (fiscal number). Netherlands identification number for taxpayers.

Registered address

Attention ! If you are officially registered in the Netherlands (Gemeente), please provide a Dutch address. Otherwise, please provide an address from another country.

Contact details

Attention ! e-mail address is not required, however, we send the confirmation of benefit declaration the above-mentioned email address provided.

The applicant's insurance period

Please note ! only people insured in the Netherlands can apply for a insurance benefit

Beneficiary's income


Additional information

Attention ! optional field


Click or drag files to this area to upload. You can upload up to 10 files.
Please note ! only PDF & JPG file format are accepted (max size 2 Mb each file)

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