Insurance Application Formsend to: I want to become a member of TK as of _____________________

Erste Beschäftigung EU MG Besch an Fax in englisch Relocation Service

Fax: 0711 / 45 95 087

Ms. Mr.

Name _________________________________________________

First Name _____________________________________________

Date of birth ____________________________________________

Street, number _________________________________________

Postcode, town __________________________________________

Telephone* _____________________________________________

E-Mail* ________________________________________________

Pension insurance number _________________________________

If you don't have a Pension insurance number, we require the following additional details:

place of birth ____________________________________________

birth name ______________________________________________

nationality ______________________________________________

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

Name, town _____________________________________________

from ____________________ until __________________________

compulsory insurance voluntary insurance

family insurance

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

Last name, first name of insured member _____________________

_______________________________________________________

Date of birth ____________________________________________

I am enclosing a copy of my passport.

I will hand this copy in at a later time

Disclosures for insurance with Techniker Krankenkasse

I am employed as a ______________________________________

This is my first job as an employee ,EUAbkommenstaat Yes No

I am self-employed (incl. shareholders) Yes No

Name of employer ___________________________________

Street, number _______________________________________

Postcode, town _______________________________________

Commencement of employment _____________________________

I am exempt from compulsory health insurance Yes No

I am exempt from long-term nursing care insurance Yes No

I am exempt from pension insurance Yes No

My gross monthly salary excluding benefits (or total income in the case of non-employees) is EUR ___________

My non-recurring benefits (e.g. Christmas orvacation bonus p.a. equal EUR ___________

I receive or have applied for a pension Yes No

I receive benefits (company pension) Yes No

Family insurance

I have relatives (wife/husband, children)who are to be included in my insurance Yes Noat no extra charge

Participation in TK-Exclusive

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

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

Date ________________ Signature _________________________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.

* voluntary Information

It is my wish to recieve the documents by e Mail. The rules of German data protection are known.Please attach your passort copy!