Applicant’s personal information
Your date of birth
Your address
Postal code Town
Your nationality
French EU/EEA/Switzerland
((1) – see list on back) other
Your telephone number
I hereby attest to the accuracy of all the information I have provided in this application.
Signed at
Applicant’s signature
Signed statement to be completed by the applicant
Town and country of birth
(*) Metropolitan France, French Guiana, Guadeloupe, Martinique, Reunion, Saint Barthelemy, and Saint Martin.
(Last name at birth, followed by the last name you use (optional and if applicable), then your first and middle
names as they appear on your birth certificate)
(If you are an artist-author and use a pseudonym, enter it after your last name).
Your social security number (if you have one)
Your benefits claimant number (“N° d’allocataire” for family benefits, if you have one).
Family benefits fund name “Caf de…..”
If you do not have a personal address, enter the name and address of the organization you are using as your home address
(This can be a “Centre Communal d’Action Sociale” or an approved membership organization)
Postal code Town
I hereby agree to immediately notify the health insurance institution to which I am submitting this application of any change to the
information in box A and of any transfer of my main residence to another country.
IMPORTANT: if you have dependent minor children, please refer to the guide.
(Articles L. 160-1, L. 160-2, L. 160-5, L. 161-1, R. 111-3, and D. 160-2 of the French Social Security code
in de permettre votre affiliation au régime général sur c
Application for membership in
the French health care system
Applicant’s employment circumstances
Not employed
specify :
f you are a member of another country’s social security system, e.g. as a worker on a posting to France from another country or
as a pensioner, do not f
ill out this form. To set up coverage for your
self and your family members, you will need to submit an
S1 form “Registering f
health care cover in the State of residence,” or an equivalent document for non-EEA countries, to your
local health insurance f
To be eligible for coverage of your health care expenses in the event of an illness or pregnancy and childbirth, you
must be working in France (*) or, if you are not working, you must be a legal ongoing resident of France.
specify type of employment :
French law N° 78-17 of January 6, 1978 (amended) on data processing, data files, and individual liberties applies to the information gathered through this form. It entitles you to
access and rectify the information in your file by contacting your health insurance organization.
Supplying false or fraudulent information with the aim of obtaining undue benefits either for oneself or for a third party (articles 313-1 to 313-3, 433-19, and 441-1 et seq
of the French Penal
Code) is punishable by a fine and/or imprisonment.
In addition, any provision of incomplete or inaccurate information or failure to report a change in circumstances with the aim of obtaining undue benefits either for oneself or for
a third party can result in a monetary sanction pursuant to article L 114-17-1 of the French Social Security Code.
The health insurance institution can conduct verifications at any time by requiring you to submit documentary evidence of your circumstances (articles L. 114-10-3 and
L.161-1-4 of the French social security code).
Your email address
To ensure that you are entitled to health care coverage as soon as you come to France, if you are not already a member of
a French social security scheme, you will need to fill out this form and return it to the health insurance fund that covers
your place of residence, along with the required documents listed on the back. If you are a family member (spouse,
common-law or civil union (“PACS”) partner, etc.) of a French-insured individual working or residing in France
in a legal
and ongoing manner whom you are moving to France to accompany or join, you will also need to fill out this form.
and decree of May 10, 2017, which sets forth the list of acceptable residency permits)
date of arrival in France
Supporting documents
You are required to submit the following:
Your official banking information slip showing your IBAN number (“relevé d’identité bancaire”).
For the payment of your benefits
List of EU/EEA countries:
Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, Republic of Slovakia,
Romania, Slovenia,Spain, Sweden, United Kingdom,.
If you have dependent minor children
A photocopy of your ID card or passport
As proof of your identity and the legal nature of your
residency in F
rance if you are citizen of a state outside the
EU/EEA (1) and Switzerland
en France (métropole, DOM, Saint-Pierre et Miquelon,
Saint-Barthélemy, Saint-Martin) :
- une copie d'une pièce d'Etat civil (carte nationale d'identité, livret de famille
à jour, passeport).
Si vous êtes né
If you are employed
As proof of identity if you are a French citizen or a citizen
of another EU/
EEA(1) member State or Switzerland
A photocopy of your currently valid residency permit or residency document, such as a
multi-year or temporary residency permit (“carte de séjour pluriannuelle”/ “carte de
séjour temporaire”), residency card (“carte de resident”), a residency permit (“carte de
séjour”) marked “compétences et talents,” a certificate of residency for Algerian citizens
(“certificate de residence de ressortissant agérien,”), a long-stay visa valid as a residency
permit along with the pages of your passport showing your identifying information, a
certificate of application for asylum, or a temporary residency authorization (“autorisation
provisoire de séjour”).
Your health insurance fund will let you know if you need to have it
A long-form copy of your birth certificate, or a short-form copy of your birth
certificate showing your parents’ information, or an equivalent document issued by
a consulate. (This document must be authenticated, specifically by a legible stamp.)
A photocopy of any documentation of your employment, such as your
employment contract or a pay slip
To obtain your social security number if you do not know it,
and if you were born abroad or in Wallis and Futuna
To prove the ongoing nature of your residency in France if
Any documentation of this circumstance
if one of the following circumstances applies:
- y
ou are drawing one of the following benefits:
- you are registered as a student at an educational facility or
as a trainee through a cultural, technical, and scientific
- you are returning to France after participating in an international
volunteer program abroad,
you have re
fugee, subsidiary protection, or asylum
seeker status,
if none of the above circumstances applies:
- you are a family member of a French-insured individual working or
residing in France in a legal and ongoing manner whom you are moving
to France to accompany or join,
family benefits (“allocations familiales”), housing aid, AAH, RSA,
minimum old-
age pension ASPA, ASI, or family and social re-
engagement aid (“aide à la reinsertion familiale et sociale”) which
helps former migrant workers rebuild ties with their home
- you are a young minor or under age 21 and receiving services
through a facility or program belonging to the French child and
youth protective services “Aide sociale à l’enfance” or
“Protection judiciaire de la jeunesse.”
Any document that proves that you have been residing in France for more
than three months.
Examples: a lease or rental agreement, consecutive rent receipts,
consecutive utility, water, or landline telephone bills, hotel bills for the past
three months, certificates of school enrolment, etc.
If you are being lodged by a private citizen: a signed statement written
by that person, specifying the date on which you began lodging with
them, along with consecutive rent receipts or utility bills issued in their
name for the past three months.
If you are lodging at a “centre d’hébergement et de reinsertion
sociale,” a lodging certificate for the past three months issued by
the center where you are staying.
If you do not have a personal address and have chosen the premises of
an approved organization as your address, a certificate of chosen
address issued by that organization which covers more than three
A completed S3705 form (“Application to add minor children to one or
both parents’ insurance accounts”). This form is available for
download on or in paper format from your health
insurance fund.