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Forms

All the forms for your insurances gathered here.

Outpatient care 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
        
Outpatient care                                                                  

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

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