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Fill in the form and access the Business Portal

Fill in your company details and preferences below and we will then send you a customised third-party payer agreement.

COMPANY INFORMATION

Official name of third party payer* 

Street name* 

No*

Box

Postal code*

City*

VTA number (BE xxxx-xxx-xxx) 

Company number (xxxx.xxx.xxx) 

The name of the registered office is not the same as the "third party payer official name"

Head office name 

Streetname

No

Box

Postal Code

Gemeente

Local authority 

CONTRACT PROPOSAL INFORMATION

Beneficiary type* 

Estimated number of users* 

Total number of employees* 

Start date contract* 

Percentage intervention (min. 72%)* 

Intervention MOBIB card*

* required fields