(E) 106 form

Declaration Dutch health insurance

With the 106 form, you can prove to healthcare insurers in your country of residence that you have Dutch health insurance. As such, you are entitled to medical care in your country of residence. If you are insured with HollandZorg, you can ask HollandZorg for the 106 form.

Apply for the 106 form from HollandZorg

If you have taken out HollandZorg Public Healthcare Insurance, you can ask for a 106 form by calling our Customer Services on +31 (0)570  687 123 or by using our online application form.

What's even more important to know:

• when you enroll in your municipality in Netherlands (Dutch primary registration people (BRP)) then comes the E-106/S1 form lapses.   
• We fill the form E-106-/S1 after request fully in. This fully completed forms as soon as possible, usually you must personally and within 6 months in to the health insurance of your home country.   
• The E-106/S1 form is valid with effect from registration date to the date of deregistration of your health insurance.

Apply for 106 form

Register with a healthcare insurer in your country of residence with a 106 form

Once you have received the 106 form from HollandZorg, you use it to register with a healthcare insurer in your country of residence. Do you have a (legal) partner or children? The healthcare insurer in your country of residence decides which family members will be co-insured.

Which healthcare is available with the 106 form?

With the 106 form, you are entitled to the statutorily insured medical care in your country of residence. You are also entitled to all care covered by the HollandZorg Public Healthcare Insurance. The reimbursements of this healthcare are according to Dutch criteria. Costs you incur in your country of residence will not always be reimbursed in full. This depends on the healthcare and your country of residence. Read the HollandZorg insurance conditions (PDF) for more information.