Statement of membership - Deutsche BKK

Statement of membership
(Please print your responses)
Details of family members' last previous or existing insurance policy
Spouse
Child 1
Child 2
Child 3
Dear prospective client,
Date:
Date:
Date:
Date:
Name:
Name:
Name:
Name:
please complete and sign the declaration of membership and return a scanned copy
via e-mail to [email protected] – thank you.
The previous insurance policy ended on …
was taken out with … (name of health insurance fund)
Type of previous
insurance policy
Your Deutsche BKK
Membership Membership Membership Membership Family insurance
Family insurance
Family insurance
Family insurance
Non-statutory
Non-statutory
Non-statutory
Non-statutory
Where a family insurance policy
was taken out, surname and first
name of the person from whose Surname:
membership the family insurance
policy was derived
First name:
Deutsche BKK • 38439 Wolfsburg • www.deutschebkk.de
[email protected] • Phone: +49 (0) 80 06 64 90 98*
* Free of charge from a German landline or mobile phone.
Surname:
Surname:
Surname:
First name:
First name:
First name:
I would like to become a member on
The previous insurance policy
is continuing with:
Personal information
Other details of family members
Spouse
Child 1
Child 2
Child 3
Yes
Yes
Yes
Yes
male have never been health-insured.
have been health-insured since
female
by
Health insurance company’s name and address
First name, Last name
Earnings from self-employment (monthly; please enclose a
have been self-insured.
copy of the current income tax
assessment.)
Euros
Euros
Euros
Euros
Gross income from marginal
employment (monthly)
Euros
Euros
Euros
Euros
Is Arbeitslosengeld II
(Unemployment Benefit II)
received?
Present health insurance / long-term care insurance
Up to this date I
(name of health insurance fund)
Self-employed
.
Nationality
have been family-insured through:
Street address
Member‘s last name, First name
Postal code/Town
Yes
Yes
Statutory pension, pensions
and related benefits, company
pension, foreign pension,
other pensions (monthly payment)
Yes
Yes
Date of birth
insured since
Daytime telephone number (Voluntary)
Please attach proof of your previous health insurance.
Euros
Euros
Euros
Euros
Other regular monthly income
within the meaning of the
Income Tax Law E-Mail (Voluntary)
I had previous health insurance in Germany until
Date of birth
(e.g. gross income from more-thanmarginal employment, income from
rent and leasing, income from capital)
Euros
Euros
Euros
Euros
Type of income
Type of income
Type of income
Type of income
School attendance/studies
by
Health insurance company’s name and address
Place of birth
My work contract commenced on / will commence on
Country of birth
as
(for those aged 13 and over, enter the
expected end date; NB: for those aged
23 and over, enclose school/study
certificate)
Military or civilian service
(please enclose certificate of service)
from
from
from
Maiden name
to
to
to
Tax identification number (by providing your tax ID, you consent to the data being sent to the fiscal authorities in accordance with Section 10 (2a) of the German Income Tax Law (EStG)).
from
from
from
to
to
to
Details of allocation of a health insurance number for relatives covered by family insurance
Spouse
Child 1
Child 2
Child 3
Own pension insurance
number (RV no.)
with
Pension insurance number
Maiden name
Signature
P
lease apply for my pension insurance number / social
insurance card.
I have a child / children.
yes no
Family insurance
Place of birth
Country of birth
I am applying for non-contributory family insurance
for my dependents (spouse / children).
Nationality
I confirm that these details are true and accurate. I will inform you immediately in the event of any changes. This applies in particular if my income or that
of other family members changes (e.g. new income tax assessment for self-employment) or if they become members of an(other) health insurance fund.
Place, date, signature of member if applicable, signature of family members
By signing, I confirm that I have received the family members' consent to provide the necessary data.
Where family members are living separately, the signature of the member shall suffice.
Data protection notice (section 67a para. 3 of the Code of Social Law (SGB) X): So that we can assess the family insurance, you must comply with section 10 para. 6, 289 of the Code of Social Law (SGB) V. The
data is to be gathered in order to ascertain the insurance relationship (section 10, 284 of the Code of Social Law (SGB) V, section 7 of the Law on Health Insurance for Farmers (KVLG) 1989, section 25 of the
Code of Social Law (SGB) XI). Contact details provided voluntarily will be used solely for queries relating to your insurance relationship.
Employer’s name and address
yes (please complete the following application)
I agree to having my contact details (name, address, health insurance number, e-mail and
telephone number) saved for information purposes regarding new products and services and
that the Deutsche BKK will inform me by telephone or e-mail in this regard. I can revoke my consent
at any time.
I hereby consent to my data being sent to the fiscal authorities in accordance with Section 10 (2a) of the German Income Tax Law (EStG). (Please state your tax identification number.) If the
tax identification number is not entered or is not correct, this consent also includes consent for
your tax identification number to be requested electronically from the Federal Central Tax Office.
no
Place, Date, Member’s signature
This information is collected based upon the regulations of the German Social Code and will only be used to comply with statutory requirements by our health insurance company. Your data will be handled in strict confidence and is subject to data protection laws. Provision of your telephone number and e-mail address is voluntary.
Version: February 2014
Please turn over
Application to take out family insurance
Questionnaire for inclusion
in the family insurance policy
1. General information
General details of the member
Applicant‘s last name and first name, date of birth, health insurance number
Up to now,
I have
not been insured by a statutory health insurance company.
been insured as a member of
been insured as part of a family insurance policy with
Applicant's surname, first name, date of birth and health insurance number
Health insurance company’s name and address
Health insurance company’s name and address
Member‘s name and date of birth
Marital Status:
single married separated divorced since civil union according to the German Civil Partnership Act LpartG (Please use “spouse section”)
My spouse has his/her own health insurance no During the day I can be reached at yes, with
widowed
or by e-mail
. (Voluntary information)
Spouse
Child
Child
male female
male female
male Name of health insurance fund
not covered by statutory health insurance.
Marital status:
single registered civil partnership in accordance with the Civil Partnership Act (LPartG) married separated divorced since widowed
Reason for inclusion in the family insurance policy:
Start of my membership
Marriage
Ending of family member's own previous membership
Birth of child
Other:
Start of family insurance:
during the day.
My email address is female
Different address, if applicable
Relationship status biological child
stepchild
(Please check or enter all relevant information)
from:
Your own insurance with the Deutsche BKK or any
other insurance company (Please include statement of income until:
in the case of private insurance.)
with:
starting on:
yes yes yes euros
Wages/salary
Self employed
Retirement payments/pension
Rental/lease income
Support payments
Wages/salary
Self employed
Retirement payments/pension
Rental/lease income
Support payments
School/College/University Please fill in anticipated date
of completion/starting after the 13th birthday
General details of family members
Spouse
starting on:
no
euros
Monthly gross income
euros
Wages/salary
Self employed
Retirement payments/pension
Rental/lease income
Support payments
from:
until:
from:
until:
Military or civilian service
from:
until:
from:
until:
Name and address of the health insurance company in
which the family has had membership until now
3. Information required to issue a health insurance number
Child 3
Surname*
First name
Gender
(m = male, f = female)
m f
m f
m f
m f
Date of birth
Member's family relationship
to the child (** The term "natural child" should also be used in the case of
adoption.)
Nationally valid health insurance number
Maiden name
Place of birth/country of birth
natural child**
stepchild
natural child**
stepchild
natural child**
stepchild
grandchild
foster child
grandchild
foster child
grandchild
foster child
No
No
No
Is the spouse related
to the child? Nationality
I declare with my signature that I have received the consent of my family members to provide the required
information. In the case of family members living on their own, their signature suffices.
Child 2
Address if different to that
of the member
Pension insurance number
I confirm that the information given is correct. I will immediately notify you of any changes. This applies
specifically to any changes to any of the family members‘ gross income, if they become a member of (another)
health insurance company, or are otherwise insured.
Child 1
no
(Important: if aged 23 or older, please attach school confirmation)
(Important: please attach period of service confirmation)
Please note that taking out family insurance with various health insurance funds at the same time is illegal. Therefore, please ensure that by
providing these details you will not have two or more family insurance policies.
from:
until:
with:
starting on:
no
In principle, the following details are compulsory only for family members who wish to be covered by our family insurance. However, we will also require specific details of your spouse/partner if our family insurance
is to cover your children only. In this case, in addition to the general details, we will require information on the insurance of the spouse/partner and, where the spouse/partner is not covered by statutory insurance
and is related to the children, information on their income. The income must be evidenced with proof of income and extra amounts, which are paid on account of the marital situation, must be disregarded from the
income details.
biological child
stepchild
from:
until:
with:
(These details are not compulsory.)
Details of family members
Date of birth
(Please check or enter everything applicable. Please include income
tax assessment if self-employed.)
insured under a family insurance policy with
(These details are not compulsory.)
First name
Type of income
In the event of queries, I can be reached on telephone number Last name (if it differs from the member’s name)
I will need a new health insurance card
Name of health insurance fund
(in this case, the details are to be provided under the "spouse" category)
Please only fill in this portion if you choose us as health insurer for your spouse or your children. Please also fill in your spouse‘s information if you choose family insurance for your children only. When entering your
spouse’s income, do not include supplements (Zuschläge) that are based on your family situation (for example, an allowance for dependent children). No information on the spouse’s income is required if he/she is a member
of statutory health insurance fund related to the children.
Please issue family insurance
insured under my own membership with
Health insurance company’s name and address
2. Family members
Gender
Until now I was
(Please tick only if there is no family relationship.)
Place, Date, Member’s signature
Signature of the family member/s, if applicable
Privacy notice (§67a sec.3 Code of Social LawX (SGB X)): In order for us to lawfully carry out our work, your cooperation is required according to §289 of the Fifth Book of the German Social Code law (SGB V).
This data needs to be collected for insurance agreement specification purposes (§§ 10, 284 SGB V).
Is a new health insurance
card required?
Yes No
Yes No
Yes No
Yes No
* Please enclose a marriage certificate or proof of descent if your spouse/partner or your children have a different surname and you have not already provided these documents.
Version: February 2014
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