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Statutory health insurance

BARMER request

Barmer Antrag EN

Personal Information
I am*
Title*
First name*
First
Last name*
Last
Birth name*
Last
Citizenship / Staatsangehörigkeit*
Date of birth*
Day
Month
Year
Place of birth
Country of birth*
Address*
Address

Street Address City ZIP / Postal Code
E-Mail*
Telefon
Children*
Children
- Yes
- No
Pension insurance number*
Do you have your pension insurance number to hand?
- Yes
- No
Pension insurance number*
Beginning of membership
- As soon as possible
Beginning of membership*
Or from
Day
Month
Year
Your university
Name of university*
University address
University address

Street / Anschrift Place / Ort Postcode / Postleitzahl
Start of study*
Start of study
- Winter semester
- Summer semester
Year of start of study*
Insurance Details
How are you currently covered by health insurance?
Are you exempt from compulsory health insurance?
- Yes
- No
Reason for the cash change*
- Change in the insurance relationship (e.g. change of employer, start of training and studies).
- Increase of the additional contribution by the current health insurance fund
- Change of health insurance fund after at least 12 months of membership with the current health insurance fund
Your insurance status
As an employee, you are voluntarily insured if you regularly earn more than 5,362.50 euros gross per month. This amount is the current compulsory insurance limit.*
As an employee, you are voluntarily insured if you regularly earn more than 5,362.50 euros gross per month. This amount is the current compulsory insurance limit.
- exempt from insurance
- subject to insurance
Your employer
Name of the employer
Address
Address

Street Address City ZIP / Postal Code Country
Data Protection & Proxy

All information on data processing can be found in our data protection regulations.
Privacy*
- With my signature, I authorise MAWISTA GmbH to transmit the application data to the statutory health insurance fund. I authorise MAWISTA GmbH to receive the social data relating to my membership. I agree that the chosen health insurance fund may transmit the identification data and information as to whether and from when membership has been established for billing purposes.
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Date
Signature of applicant/legal representative*
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Comments
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