Assurance santé etranger


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You
Name First name Date of birth
Email Telephone Purpose

day

month year

 

Others to ensure
Name First name Date of birth Student In possession of the European Health Insurance Card * Purpose **
day month year
1)
 
2)
 
3)
 
4)
 
5)

 

Coverage Period

From To

Country of origin
Country of destination
Partner code (optional) : partenai