11100063338 Membership application for people in Work ceca | woul Ike to become: member of TK a8 of Ow Ows Personal information Lastname Frstnamne Date of itn Strost No Postcode and town/city Heath Insurance Nurser You wil fin this on your hesth insur German Pension Insurance No. Pleese give the follwing details if you donot have Pension Iau ure yt: Lastname at brn Place and county af br Nationality Details of previous insurance | wos last insted with health insurance fund from to [Ly comutory insurance [7] vtuary naan he cancelation onfemation* [Ly tenctosea Details for insurance cover with TK 1 cerns surance 1 wnt nardeain br lam omployedtt er as 1c you get one-o payments such as Christmas onus or hokey bonus? 1730, please simply acd one welts ofthe oneal payments to your gross monthly income. [Z1 that myst exempted tom compuliory hesth insurance cove Zina met exempted rm computor person instance cover Please send us copies of your enfimations of exemption Retirement benefits [1 tearenty sive or hae alee stte person [Leroy gt pension re aed heeft orp pro, Family details | would tke to have my dependants (spouse/ife partner pursuant ‘a the Lebensparinerschasgeset (Cerrnan Civil Partnership At hire} covered by noncontroutory dependants’ insurance. ‘The sopiston for non-contributory depencnts” insur [Ey isenclosed [F] witb handed in titer [1] Atese ser mean aplication orm Details forTK long-term care insurance 1 am expt trom sei tng er ire nares Pease snd sw copy of ou contain of exemption 11 tar tne foe itisvers hier \We ned ns intormston to care elt your contbtons lager cae notence lease submit he eleven ct tony af the ith cerita Recruit new members and win attess ‘Queries and signature ‘The follow det help usin case of queries rai LL] tis ptr emoynenin Geran Employer Date signature X Wend your prea at Ceo ata to Carey pra uals sheet, Ne Pestcade ard taney {amin pis employe sof ta seerploe [Lam paren at managing retort Gb nt lied conpan My gross monty income [Ly erceeas he cent annual 50 euros (min for you This is based on S Security Cove ane Section Securty Coo ion 284 SozialgsetebuchV ISG Vi (Socal Sonilgesetzbuch XI (SCE XI (Sorat * We might need a confirmation of cancelation This depends on your previous neath insurance cove Please get in touem wth your contact person Visi wrwnth de, webcede 4800, for information about the current annualincome lit. Unfortunately this information is cnly avaiable Getran st present. 4 Optional information Please forwat ieation to Ansrea Rothe Fax 0800.78 58 6895 06 26 {alreo within Germony Andrea Rotne@tke roam WE Krankenkasse