Your forms

Healthcare
  

 

TIP: You can easily report your hospital admission online via ag.be/hospi. It's also your go-to source for information on how to claim back your medical expenses online.

   
Below you will also find all the necessary forms to report your admission in writing or claim your refund.


  
Reporting a hospital admission


• Claim form

 
• Medical certificate          
You only need to fill out this form if explicitly directed to do so by our medical department.

NL - FR - EN - DE

       


 

Request for reimbursement of medical expenses (hospitalisation, outpatient care and critical illnesses)

NL - FR- EN- DE


  

Additional information when enrolling in a group hospital plan

 
 

Individual continuation of group hospital plan


 

SEPA attestation (European direct debit)

 

Fact sheets (IPID)

IPID stands for Insurance Product Information Document. This document gives you useful, simple and concise information about your insurance. It is drawn up in accordance with the legal provisions of Assuralia, the professional association of insurance companies in Belgium.

• Group hospitalisation plan

NL - FR - EN


• Group outpatient care plan

NL - FR - EN


• Group dental care plan

NL- FR - EN