Insurance benefit

Insurance benefit declaration in the Netherlands

Tax year

Date of completing the form *

Select the insurance benefit year *

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

The beneficiary's personal data

Surname and name *

Date of birth *//

Attention ! valid date format: day-month-year

BSN number *

Attention ! BSN - burgerservicenummer (fiscal number). Netherlands identification number for taxpayers.

Citizenship *

Marital status *

Registered address

Street name and number *

Post code and city *

Country *

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

Phone number *

E-mail adress

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

Were you insured in the Netherlands during the benefit year? *

Yes
No

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

Date of insurance / from: *

Please note ! the insurance period (s) are required

Date of insurance / to: *

Please note ! the insurance period (s) are required

Do you need to give more insured periods in the benefit year? *

Yes
No

Please note ! all the insurance period (s) are required

Date of insurance / from:

Attention ! or the date of being on the unemployment benefit (sickness, unemployed)

Date of insurance / to:

Please note ! all the insurance period (s) are required

Date of insurance / from:

Please note ! all the insurance period (s) are required

Date of insurance / to:

Please note ! all the insurance period (s) are required

Date of insurance / from:

Please note ! all the insurance period (s) are required

Date of insurance / to:

Please note ! all the insurance period (s) are required

Beneficiary's income

Have you had income in the Netherlands in the benefit's year ? *

Yes
No

Enter your annual brutto amount of income in euros in the Netherlands in the benefit's year *

Have you had additional income outside the Netherlands in the tax year (e.g. in your country)? *

Yes
No

Enter your annual brutto amount of income in euros outside the Netherlands in the benefit's year *

Enter the country in which you had income outside the Netherlands in the benefit's year *

Partnership

Are You married or have a partner? *

Yes
No

Surname and first name of your partner *

Date of birth of your fiscal partner *//

Partner's insurance

Should we also do your partner's insurance benefit declaration? *

Yes
No

Attention! if the answer is "Yes", the partner's information is required!

Additional information

Additional information affecting the insurance benefit declaration

Attention ! optional field

Personal data of the partner

Partner's BSN number *

Attention ! BSN - burgerservicenummer (fiscal number). Netherlands identification number for taxpayers.

The partner's nationality *

Marital status of the partner *

Partner's registered address

Partner's street name and number *

Partner's postcode and city *

Country *

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

Partner contact details

Partner's phone number *

Partner's e-mail address

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

Partner's insurance

Was the partner insured benefit in the Netherlands during the benefit's year? *

Yes, he(she) was insured in the Netherlands
No

Please note ! the insurance period (s) are required

Date of insurance / from: *

Please note ! the insurance period (s) are required

Date of insurance / to: *

Please note ! the insurance period (s) are required

Do you need to give more partner's insurance periods in the benefit's year? *

Yes
No

Please note ! all the insurance period (s) are required

Date of insurance / from:

Please note ! all the insurance period (s) are required

Date of insurance / to:

Please note ! all the insurance period (s) are required

Date of insurance / from:

Please note ! all the insurance period (s) are required

Date of insurance / to:

Please note ! all the insurance period (s) are required

Date of insurance / from:

Please note ! all the insurance period (s) are required

Date of insurance / to:

Please note ! all the insurance period (s) are required

Beneficiary partner's income

Have your partner had any income in the Netherlands in the benefit's year? *

Yes
No

Enter your partner annual brutto amount of income in euros in the Netherlands in the benefit's year *

Have your partner had additional income outside the Netherlands in the benefit's year (e.g. in another country)? *

Yes
No

Enter your partner annual brutto amount of income in euros outside the Netherlands in the benefit's year *

Enter the country in which your partner had income outside the Netherlands in the benefit's year *

Attachments

The following documents are required: jaaropgave, a copy of ID (ID card or passport - documents should be sent in accordance with the principles of personal data protection - AVG - NL) *

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)

Terms and conditions

Agreement *

Yes, i agree to the terms and conditions
No

I have read and agree to the Privacy Policy" "I accept the Terms of Service