Formulaire

Application for solidarity-based supplementary health insurance

Cerfa 12504*14 (S3711n)

This form allows you to apply for complementary health solidarity.

This form includes an integrated leaflet.

The form contains a list of supporting documents and information on the composition and resources of your household, the specific situations relating to the RSA and the choice of complementary organization.

You must send your request to your health insurance body.

    Fill out the form

    For details, please use the practical information sheets :

    J'ai réalisé une démarche administrative

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

    Je donne mon avis

    Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)

    Verified 25 August 2026 - Public Service / (Prime Minister)