How to fill in CERFA 15763 (French health insurance)

What the form is for

With this form you ask the CPAM (the health insurance office where you live) to cover your health costs under the PUMa (protection universelle maladie), if you are not already covered by a French scheme. You print it, sign it and send it with the documents listed on its back.

Family members who join or come with someone who works or lives in France (spouse, partner, PACS partner) fill in their own form too.

It is not for people covered by another country's social security, such as posted workers or pensioners: they give their health insurance office an S1 form, or an equivalent document for countries outside Europe.

Who needs it

You can get the PUMa if you work in France, or if you live in France in a stable and regular way. Both conditions about residence apply together:

• Regular residence: citizens of the EEA and Switzerland only need an ID card or passport. Other nationalities need a residence permit or residence document.
• If you work in France and your request is accepted, you are covered straight away.
• If you don't work, you must have lived in France for 3 months before your rights open, and you keep them if you live in France at least 6 months a year.
• Some people don't wait the 3 months, for example refugees, people back from an international volunteering mission, or people receiving the AAH or ASI disability allowances.
• Joining the social security is compulsory: refusing on purpose can be punished with 6 months in prison and a €15,000 fine.

Before you start

• EEA or Swiss citizens: a photocopy of your ID card or passport. Others: a photocopy of your valid residence permit or document (for example a residence card, a long-stay visa that counts as a residence permit, an asylum application certificate) with the passport pages showing your identity.
• If you were born abroad and don't know your French social security number: a full copy of your birth certificate or an extract with your parents' names (or an equivalent document from a consulate). The CPAM tells you if it must be translated.
• If you work: a copy of a document proving it, such as your employment contract or a payslip.
• If you don't work: proof that you have lived in France for more than 3 months, such as a lease, rent receipts, energy, water or landline bills, hotel bills or school certificates. If someone hosts you, their sworn statement with their own bills.
• If you have children under 18: form S 3705 to attach them to you or to both parents.
• Your bank details (RIB with your IBAN) for reimbursements.

Section by section

The form is in German. Here is what each part asks, in plain words, in the order it appears.

1. 1

   A Identification: Vos nom et prénoms

   Your birth family name, then your usual name if different (optional), then your first names in the order of your civil status documents.

2. 2

   N° de sécurité sociale, N° d'allocataire

   Your French social security number and its 2-digit key, and your CAF benefits number with the CAF's town, only if you already have them. Newcomers usually leave these empty.

3. 3

   Date de naissance, Commune et pays de naissance

   Date of birth in the boxes, one digit per box (day, month, year), then town and country of birth.

4. 4

   Votre nationalité

   Tick one: française, UE/EEE/Suisse (the list of countries is on the back), or autre for every other nationality.

5. 5

   Adresse, téléphone, courriel

   Your address in France, postcode and town, phone and e-mail. In the fillable PDF the e-mail box only takes 10 characters: if yours is longer, write it by hand after printing.

6. 6

   No personal address?

   Only if you have no address of your own: the name and address of the body where you have a postal address (élection de domicile), for example a CCAS or an approved association. Otherwise leave it empty.

7. 7

   B Situation au regard de l'emploi

   Tick Activité professionnelle and say which one, or Sans activité (no job), or Autre and explain. Then the date you arrived in France.

8. 8

   C Attestation sur l'honneur

   You promise to report changes in part A and any move abroad, and confirm the information is true. Write the town (Fait à), the date (Le) and sign.

Common mistakes

• Ticking the wrong nationality box

  "UE/EEE/Suisse" is only for the countries listed on the back of the form. Every other nationality is "autre", and then a residence permit is required.

• Expecting coverage from day one without a job

  Without work, rights open after 3 months of residence (unless you are in one of the exceptions). Send proof that covers those 3 months.

• Using this form when another country covers you

  Posted workers and pensioners covered by another country use an S1 (or equivalent) instead.

• An e-mail that doesn't fit

  The official PDF limits the e-mail box to 10 characters. Write a longer address by hand rather than leaving it cut off.

• Forgetting the children's form

  Children under 18 are attached to a parent with form S 3705, sent with your request.

• Sending copies that can't be checked

  Birth certificates from abroad must be authenticated (for example with a readable stamp). Send clear photocopies; keep the originals.