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Insurance Application Form

send to: Carmen.Duecker@TK.de


I want to become a member of TK as of ____________________

Disclosures for insurance with Techniker Krankenkasse

Erste Beschftigung EU
Service

I am employed as a _____________________________________

Fax:

Ms.

MG Besch an Fax in englisch Relocation

0711 / 45 95 087

Mr.

This is my first job as an employee ,EU


Abkommenstaat

Yes No

I am self-employed (incl. shareholders)

Yes No

Name ________________________________________________

Name of employer

First Name ____________________________________________

Street, number

______________________________________

Date of birth ___________________________________________

Postcode, town

______________________________________

Street, number

Commencement of employment ___________________________

________________________________________

__________________________________

Postcode, town _________________________________________

I am exempt from compulsory health insurance

Yes No

Telephone* ____________________________________________

I am exempt from long-term


nursing care insurance

Yes No

I am exempt from pension insurance

Yes No

E-Mail* _______________________________________________
Pension insurance number ________________________________
If you don't have a Pension insurance number, we require the
following additional details:

My gross monthly salary excluding benefits


(or total income in the case of non-employees) is EUR _________

place of birth ___________________________________________

My non-recurring benefits (e.g. Christmas or


vacation bonus p.a. equal

birth name _____________________________________________

EUR _________

I receive or have applied for a pension

Yes No

I receive benefits (company pension)

Yes No

nationality _____________________________________________
Details of previous insurance
(During the last 18 months I was the following health insurance found(s))

Family insurance

Name, town ____________________________________________

I have relatives (wife/husband, children)


who are to be included in my insurance
at no extra charge

from ____________________ until _________________________

compulsory insurance voluntary insurance


family insurance

Yes No

Participation in TK-Exclusive

Yes, I would like to participate in TK-Exclusive.


If you were covered by family insurance, we require the
following additional details:

I am aware of the terms and conditions of participation (www.tk-online.de)

Last name, first name of insured member ____________________


______________________________________________________

Date ________________ Signature _______________________

Date of birth ___________________________________________

* voluntary Information

I am enclosing a copy of my passport.


I will hand this copy in at a later time

We require your personal particulars in order to be able to give you the best possible advices and service (Code of Social Law V= SGB V).
The code of Social Law obliges us to treat your personal particulars confidentially.

It is my wish to recieve the documents by e Mail.


The rules of German data protection are known.
Please attach your passort copy!