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Apply for a document S1/form 121

Last modified: 22 March 2023

You must apply for a document S1/form 121 from the CAK if you:

  1. Have a statutory pension or benefit from the Netherlands and;
  2. You live or go to live in a treaty country and;
  3. You no longer work in the Netherlands and you do not own a business.

How do I apply for a document S1/form 121?

  1. Download and print the form Application for a document S1/form 121 (pdf, 521 kB) (28-04-2021).
  2. Fill in the application form and sign it.
  3. Send the application form and the supporting documents to: CAK, Regeling Buitenland, Antwoordnummer 91041, 2509VC The Hague, the Netherlands.

Tip

We process your application within 4 weeks.

How do I register my family members?

In some cases, you can include your family members under your policy in your country of residence. The health insurance fund in your country of residence decides on this and lets us know.

  • You live in an EU/EEA country, Switzerland or United Kingdom: enter the details of your family members at section 5 of the application form S1/121.
  • You live in another treaty country: do not enter anything at section 5. Report your family members to the health insurance fund in your country of residence when you register there.

What can you expect after you applied for a S1/121?

You will be notified within 4 weeks. There are 3 options.

We approve your application

You will receive a document S1/form 121. This allows you (and your family members) to register with the health insurance fund in your country of residence. Your country of residence will cover your healthcare costs with the Netherlands. You will have to pay a healthcare contribution to the CAK. This amount is deducted monthly from your pension or benefit.
Please note: In some countries we send the document S1/form 121 directly to the health insurance fund in your country of residence. We will inform you if this is the case.

Tip

If the effective date of your pension and/or relocation is in the past, you are usually also insured retroactively. You will then pay a treaty contribution from that date.

We need additional information from you

We may need additional information to assess your application. We will send you a letter containing the questions we still have.

We reject your application

You are not entitled to health insurance through the CAK. The letter you will receive from us will tell you why. Do you not agree with the rejection? Then you can always object.

Why do I have to apply for a document S1/form 121?

If you emigrate, your Dutch health insurance expires. Are you still receiving a statutory pension or benefit from the Netherlands and are you moving to or do you live in a treaty country? Then you must insure yourself for medical expenses through the CAK. That is what the Netherlands agreed with the treaty countries. You do not have the choice to arrange your own health insurance. Your country of residence covers your care costs with the Netherlands. You pay a healthcare contribution (similar to a health insurance premium) to us.

Read more on moving abroad and your health insurance

More information

Please note

Are you moving to Spain? You will need, among other things, a NIE number (evidence that you are an EU citizen, in Spanish only) to register with a Spanish health insurance company. Take into account long waiting times. Please contact the Spanish consulate (Spanish and Dutch only) in advance to inform about any more documents you need when emigrating and make appointments online.