Without obligation advice

Without obligation advice

INTERNATIONAL HEALTH INSURANCE
Name*

First Name(s)Last name
Nationality*
Country where you are staying (expat country)*

House number and street

Address line 2

Place Province

Postal CodeCountry
Date of birth*

DagMaandJaar
Day/month/Year
Gender*

ManWoman
Email - Your policy will be sent to this email*
Length*
In cm
Weight*
In kilo's
Mobile phone number: The number where you can be reached in case of an emergency.*

Country code (+66 for Thailand)Mobiele nummer
Availability by phone

The mobile phone number provided will be used to reach you in the event of hospitalization or an emergency. Make sure you can be reached on this number at all times.
Passport number *
Pre-existing conditions - (fill in truthfully, Wrlife will always request your medical data and history upon admission to hospital)*

NoYes
Mention pre-existing conditions*
Family composition*

Individual (1 person)2 Persons -(wife, spouse, partner or child under 22 years old)Family (above 4th persons is free)
Name 2nd person*

First Name(s) Last name
Date of birth 2nd person*

DagMaandJaar
Day/month/Year
Gender 2nd person*

ManWoman
Length 2nd person*
In cm
Weight 2nd person*
In kilos
Pre-existing conditions 2nd person*

NoYes
Mention pre-existing conditions 2nd person*
Name 3rd person *

First Name(s) Last name
Date of birth 3rd person*

DagMaandJaar
Day/month/Year
Gender 3rd person*

ManWoman
Length 3rd person*
In cm
Weight 3rd person*
In kilos
Pre-existing conditions 3rd person*

NoYes
Mention pre-existing conditions 3rd person*
Name 4th person

First Name(s)Last name
Date of birth 4th person

DagMaandJaar
Day/month/Year
Gender 4th person

ManWoman
Length 4th person
In cm
Weight 4th person
In kilos
Pre-existing conditions 4th person

NoYes
Mention pre-existing conditions 4th person
Name 5th person

First Name(s) Last name
Date of birth 5th person

DagMaandJaar
Day/month/Year
Gender 5th person*

ManWoman
Length 5th person
In cm
Weight 5th person
In kilos
Pre-existing conditions 5th person

NoYes
Mention pre-existing conditions 5th person
Choice of cover level*

Micro 1000 USDMicro 2000 USDMicro 5000 USDEconomy 10.000 USDEconomy 20.000 USDEconomy 40.000 USDEconomy 80.000 USDSerenity 100.000 USD (recommended)Serenity 200.000 USD (recommended)Serenity 400.000 USDSerenity 600.000 USDSerenity 800.000 USDSerenity 1000.000USDElite 2.000.000
Outpatient*

YesNo - (aanbevolen)
Dentist/optical*

YesNo - (recommended)
Deductible*

No deductible - (recommended)500 USD deductible1000 USD deductible2000 USD deductible5000 USD deductible
Payment method*

Annual - (recommended)BiannuallyQuarterMonthly
Betaalmethode*

Bank transfer - (recommended)In cashCredit card
Currencies*

THBEUROUSDGBP
copy passport

Cancelof
Did you have previous health insurance (not travel insurance) if yes please send us the policy

Cancelof
I indemnify "Stichting Nederlanders Overzee"*

"Stichting Nederlanders Overzee" is not a broker or intermediary, but plays a role as an independent recognized advisor for the insurance company "Wrlife". "Stichting Nederlanders Overzee" is not responsible for the agreement between the prospective policyholder and the insurer "Wrlife". "Stichting Nederlanders Overzee" is a non-binding advisor and both the prospective policyholder and the insurer "Wrlife" indemnify "Stichting Nederlanders Overzee" against all consequences that may arise from any agreement.
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Without obligation advice

Availability by phone