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Health Insurance Waiver Form
"I need a Health Insurance Waiver Form in both English and Dutch for an international student program running from March 2025 to December 2025, including specific provisions for EU health insurance card holders and student medical coverage requirements."
1. Personal Information: Details of the individual requesting the waiver, including full name, date of birth, BSN number, and current address in the Netherlands
2. Legal Requirements Acknowledgment: Statement confirming awareness of Dutch health insurance laws and requirements under the Zorgverzekeringswet
3. Reason for Waiver: Declaration of the specific legal grounds for requesting a waiver of mandatory health insurance
4. Duration of Waiver: Specification of the time period for which the waiver is being requested
5. Risk Acknowledgment: Statement acknowledging understanding of risks and financial responsibilities of not having health insurance coverage
6. Alternative Coverage Declaration: Information about any alternative health coverage arrangements (e.g., international insurance, coverage in home country)
7. Declaration of Truth: Formal statement confirming all provided information is true and accurate
8. Signature Block: Space for date, signature, and printed name of the individual requesting the waiver
1. Employer Declaration: Required when the waiver is related to employment with an international organization or embassy
2. Student Status Confirmation: Required for international students with alternative insurance arrangements
3. Temporary Stay Declaration: For individuals staying in the Netherlands for less than 4 months
4. EU/EEA Coverage Statement: For EU/EEA residents with health insurance in their home country
5. Previous Insurance Information: Details of any previous Dutch health insurance arrangements, if applicable
1. Appendix A - Required Documentation Checklist: List of supporting documents that must be submitted with the waiver form
2. Appendix B - Proof of Alternative Coverage: Template for documenting details of alternative health insurance coverage
3. Appendix C - Official Translations: Space for certified translations of any supporting documents not in Dutch or English
4. Schedule 1 - Legal Grounds for Waiver: Detailed explanation of qualifying conditions for health insurance waiver under Dutch law
Authors
Basic Health Insurance
Health Insurance Provider
Waiver Period
BSN Number
SVB
Alternative Coverage
Municipality
Resident
Dutch Healthcare Authority
Premium
Coverage Period
Healthcare Services
Exemption
Policy Holder
Registration Address
DigiD
CAK
European Health Insurance Card
Qualifying Event
Proof of Coverage
Mandatory Insurance Requirement
Dutch Civil Code
Declaration of Truth
Legal Representative
Declaration
Risk Acknowledgment
Data Protection
Alternative Coverage
Duration
Legal Compliance
Financial Responsibility
Verification
Documentation Requirements
Revocation Rights
Change of Circumstances
Privacy Consent
Governing Law
Signature and Authentication
Supporting Evidence
Contact Information
Emergency Provisions
Acknowledgment of Understanding
Reporting Obligations
Healthcare
Education
International Organizations
Diplomatic Services
Insurance
Public Administration
Human Resources
Immigration Services
Human Resources
Legal
Compliance
International Office
Student Services
Employee Benefits
Risk Management
Global Mobility
Healthcare Administration
HR Manager
International Student Advisor
Healthcare Administrator
Compliance Officer
Immigration Specialist
Employee Benefits Manager
International Mobility Coordinator
Legal Counsel
Risk Manager
Insurance Administrator
Global Mobility Specialist
University Registrar
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