Insurance Benefit - MOJKA Finance

1. Tax Year

Date of completing the form *

Select the insurance benefit year *

2. The Beneficiary's Personal Data

Surname and name *

Date of birth *

BSN number * Fiscal number (9 digits).

Citizenship *

Marital status *

Registered Address

Street name and number *

Post code and city *

Country * Attention! If you are registered in the Netherlands, please provide the Dutch address.

Enter country name *

Contact Details

Phone number *

E-mail address *

Bank Details for Payment

IBAN Bank Account (Direct Debit) * Business or personal account for automatic collection.

Account Holder Name *

3. The Applicant's Insurance Period

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

Yes

No

Only people insured in NL can apply.

From: *

To: *

Do you need to give more insured periods?

Yes

No

4. Beneficiary's Income

Have you had income in the Netherlands? *

Yes

No

Annual brutto income in NL (EUR) *

Have you had additional income outside Netherlands? *

Yes

No

Annual brutto income outside NL (EUR) *

Country *

5. Partnership

Are you married or have a partner? *

Yes

No

Surname and name of partner *

Date of birth of partner *

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

Yes

No

Partner's Personal Data

Partner's BSN *

Partner's Nationality *

Marital status *

Partner's Address & Contact

Street and number *

Postcode and city *

Country *

Phone number *

E-mail

Partner's Insurance

Was partner insured in NL? *

Yes

No

Partner's Income

Income in NL? *

Yes

No

Income outside NL? *

Yes

No

6. Attachments & Agreement

Additional information (optional)

Click to upload documents *

(max. 10 files at a time)

Required: Jaaropgave, Copy ID. Only PDF and JPG files are accepted (max. file size 2 MB).

I declare that all information contained in the form is current and true. I accept the Terms of Service.

Name (Signature) *