Formulaire

Application to open the rights to the Health Insurance

Cerfa 15763*02 (S 1106a)

  • Person currently without rights to the Health Insurance
  • Service free
  • 5 steps
  • Language French

Fill out the form

To whom shall I send this form ?

Comment faire ?

  1. Fill the online form
  2. Download the form
  3. Print it
  4. The sign
  5. Send it to the CPAM: titleContent (general scheme) or MSA: titleContent (farm plan) of your place of residence with the documents to be attached

The back of the form presents the documents to be provided according to your situation.

Ce formulaire concerne :

J'ai réalisé une démarche administrative

Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

Je donne mon avis

Verified 13 May 2026 - Public Service / Directorate of Legal and Administrative Information (Prime Minister)