Are you a student or a vocational trainee?

Title

First Name(s) (including middle names)

Family Name / Last Name

Nationality

Place of Birth (City)

Country of Birth

Date of Birth

Passport number

Street

No.

Postal Code

Town/City

Country

Phone Country Code

Phone Number (without country code)

E-Mail

Start date of insurance cover

I am/was last health insured:

What was your previous Health insurance provider?

I have been exempted from student insurance obligations.

I am entitled to coverage in accordance with trans-/international health insurance law.

In which semester you start your study?

In which year will you start your semester?

Do you have income from :

Street

No

Postal Code

Town/City

What is your current marital status?

Do you have a spouse and/or children?

Would you like to take out free insurance cover for dependants (spouse, civil partner pursuant to the Lebenspartnerschaftsgesetz [German Civil Partnership Act], children) (if applicable)?

How do you want to pay your insurance ?