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Forms

All the forms for your insurances gathered here.

hospitalisation Insurance

Fill in this form, sign it and return it AG Employee Benefits to the attention of your plan manager at Boulevard Emile Jacqmain 53, 1000 Brussels.


New enrolment      
Use the application for enrolment form to enrol a new employee (except the Evolulife plan).     
EN - FR - NL - DE
            
Enrolment in the healthcare plan (additional form)              
Use the application for enrolment form to enrol a new employee (except the Evolulife plan).                                                                   

EN - FR - NL - DE

A change in civil status, in the number of children,...
Use the Notification of change form to make a change in civil status, in the number of children, etc. of the affiliate. For the new enrolment of a family affiliate in the healthcare plan, use the special healthcare enrolment form.

EN - FR - NL - DE


Hospitalisation
                                                           
                                            
Claim notification      
EN FR - NL - DE

Procedure for submitting documents and/or medical costs
EN FR - NL - DE                                             
                                            
Medical certificate
  EN FR - NL - DE
                   

The information required by the Verwilghen Act
(healthcare insurance and income protection)                                                                                  
                                           

Pre-financing information document
The pre-financing information document must be provided by the employer to all of their insured employees and whenever a new person is hired. This ensures that the employer fulfils his information obligation under the Verwilghen Act. Given the severe sanctions, it is recommended that an acknowledgement of receipt be signed by the employees. 
For group hospitalisation, the employer must also provide the AG Care Vision form.
EN FR - NL - DE

AG Care Vision form
AG Care Vision is an individual hospitalisation insurance plan which meets the legislator’s objective of encouraging pre-financing.
Employers who take out group hospitalisation insurance for their employees must provide them with the AG Care Vision form and the pre-financing information document.

EN - FR - NL

Request for individual continuation coverage
This document must be provided to the employee at the latest 30 days after the end of affiliation or the loss of group healthcare insurance or income protection coverage. The document consists of two parts:
The first must be completed by the employer.         
The second is for the employee requesting individual continuation coverage.
The two documents must be sent to the employee.
EN - FRNL - DE