Prefix

Your Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of birth: DDMMYYYY

Insurance no.

German pension insurance number

If no German pension insurance number has been assigned, we will require the following information:

Family name at birth

Place of birth

Country of birth

Your health insurance cover details

Services

I was last insured or lived abroad.

Name of country

I was last

Services

compulsorily insuredvoluntarily insuredprivately insuredinsured as a dependant

Name of health insurance, city

I have been exempted from compulsory insurance cover. Important: Please send us a copy of your exemption letter.I am entitled to benefits in accordance with foreign law.

Details on income

I am employed or self-employed during my studies.

Weekly study time hours

Weekly working hours

Monthly gross pay (employment) EUR

Monthly profit (self-employment) EUR

I draw or have applied for benefits from the Agentur für Arbeit [Federal Employment Agency].I have employed at least one person for more than three months and in more than marginal employment.I simultaneously employ several people in marginal employment whose combined gross pay exceeds the minor employment threshold (currently 450 EUR).

Details on your studies

Important: Please send us your current certificate of enrolment.

I will study/have studied from/since

University / Fachhochschule

Details on pension payments

I draw a pension or have applied for a pension.I receive pension payments e.g. company pension, lump-sum payments/instalments.

Details on dependants

I would like to insure my dependants exempted from contributions. Please send me an application for non-contributory dependants' insurance.I am married or live in a civil partnership pursuant to the LPartG [German Civil Partnership Act] and my married partner/civil partner is not insured with a statutory health insurance fund.

Details on long-term care insurance

I am mother/father to at least one child. Important: Please send us proof (e.g. copy of the birth certificate).

For queries

Telephone, optional information

E-Mail, optional information

Date, signature (legal representative, if applicable)

We require personal data (social data) in order to carry out our tasks correctly. The legal basis for this is Section 284 German Social Security Code,
Book V [SGB V] and Section 94 German Social Security Code, Book
XI [SGB XI]. The information about TK's data processing pursuant to
Article 13 GDPR is available on tk.de/dataprotection.
Hereby I am informed that TK informs the sales partner for billing purposes
about a membership that has come about.

Beratung erfolgt durch:

Gesellschaft, Name

PLZ, Standort

Telefon

TK-Partnernummer