Statutory health insurance BARMER request Note: Unfortunately, there is no BARMER insurance option for those over 30 years of age. Barmer Antrag EN Personal Information I am*I amIn trainingIn studyEmployedIndependentworking studentOtherwise insuredTitle*TitleMs.Mr.DiverseFirst name* First Last name* Last Citizenship / Staatsangehörigkeit* Date of birth*Note: Students over the age of 30 cannot take out insurance with BARMER. Employees can insure themselves with BARMER or switch to BARMER regardless of their age.Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Place of birth Country of birth* Address*Address Street Address City ZIP / Postal Code E-Mail* TelefonChildren*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 fromMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your universityName of university* University addressUniversity address Street / Anschrift Place / Ort Postcode / Postleitzahl Start of study*Start of study Winter semester Summer semester Year of start of study* Insurance DetailsHow are you currently covered by health insurance?How are you currently covered by health insurance?Self-insured (statutory)Family insurance (statutory)Not legally insuredAre 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 AddressAddress Street Address City ZIP / Postal Code CountryAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCubaCuraçaoCôte d'IvoireDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGhanaGibraltarGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongIndiaIndonesiaIranIraqIsle of ManIsraelJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLebanonLesothoLiberiaLibyaLiechtensteinMacaoMadagascarMalawiMalaysiaMaldivesMaliMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPuerto RicoQatarRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSri LankaSudanSurinameSvalbard and Jan MayenSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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. HiddenDate Signature of applicant/legal representative*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
