Apply for your international insurance certificate A111

For medical care in the Netherlands you need an international insurance certificate A111. Fill in the form to apply for one.

Please send us a copy of your and possibly those of your accompanying family members:

  • medicare card
  • passport. Please cover the photo and ID number. Due to the privacy law, we are not allowed to register this data in our administration.
  • residence permit (if applicable for the stay in the Netherlands)

These documents are needed to check whether you are entitled to an insurance certificate A 111. Here you can add a photo or PDF of the documents.

Attachments have to meet the following requirements:

  • The file has the extension doc, docx, xls, xlsx, pdf, jpg, jpeg or png
  • You can upload up to 20 MB. If you need to upload multiple files, then together they can be no more than 20 MB.
You have not yet uploaded any files