Health Insurance Waiver Form Template for Netherlands

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Key Requirements PROMPT example:

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."

Document background
The Health Insurance Waiver Form is a crucial document in the Dutch healthcare system, where health insurance is mandatory for residents under the Zorgverzekeringswet. This form is specifically designed for situations where individuals may legally qualify for exemption from this requirement, such as international students with adequate coverage from their home country, employees of international organizations, or temporary residents staying less than four months. The document ensures compliance with Dutch healthcare legislation while protecting both the individual and relevant institutions by clearly documenting the waiver decision and associated responsibilities. It includes comprehensive personal information, legal acknowledgments, and supporting documentation requirements, making it essential for proper healthcare administration in situations involving international mobility or special status under Dutch law.
Suggested Sections

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

Optional Sections

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

Suggested Schedules

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

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Relevant Industries

Healthcare

Education

International Organizations

Diplomatic Services

Insurance

Public Administration

Human Resources

Immigration Services

Relevant Teams

Human Resources

Legal

Compliance

International Office

Student Services

Employee Benefits

Risk Management

Global Mobility

Healthcare Administration

Relevant Roles

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

Industries
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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