Yes, I would like to join BARMER starting
My membership application should use the following information
e-mail:
[email protected] Personal details
Last name, first name Title Gender Date of birth
f m
Address Phone number 1) Mobile number 1)
Postcode Town Email address 1)
State pension insurance no. Health insurance no. Maiden name 2)
Marital status Place of birth 2) Nationality 2)
Single/not married Married Civil partner 3)
Details of eligibility for membership
Due to my income,
Since I am
subject to compulsory
Status Trainee/Apprentice Employee Managing partner/manager health insurance.
employed/working as at employer/company exempt from health insurance.
in terms of health insurance.
I am related to my employer,
since related by marriage, etc.
Expected date
I have been a student of graduation Please attach proof of enrolment!
4)
I have been (e. g. self-employed, at school, not working) since
and have been drawing/expect to draw
I have been/will be unemployed since/as of unemployment benefits or ALGII 5) since/as of
I have been drawing a state or applied for my retirement (also applies to foreign
retirement pension since pension on retirement pensions 5))
I have income similar to a retirement pension (retirement pay, pension etc.) or I have received a lump-sum payment within the last ten years 5)
I own a farming business or I work in a family-run farming business
Details of previous health insurance
Health insurance provider
I was last
insured from until by
πC
onfirmation of cancellation from
insured as individual previous health insurance provider is enclosed will be sent later
Last name, first name Date of birth Health insurance number
covered by family
insurance policy of
have not been covered by statutory Reason
health insurance since (e. g. privately insured, abroad):
General information Signature
I have a physical injury/health impairment 6)
I have children (also applies to stepchildren, adopted or foster children; Date, signature
details are needed to calculate the contributions for long-term care insurance)
In general, joining a health insurance fund also entails joining long-term care insurance,
provided you are not exempted from this.
I know other people who might be interested in joining BARMER
1)
Optional For your information: Your data are processed for the purpose of clarifying the insurance contract in
2)
Only required if no state pension insurance number provided ccordance with Sections 5 et seqq. SGB Title V, and for collection of premiums in accordance with
a
Same-sex partnership as defined by the law governing civil partnerships
3)
Sections 226 et seqq. SGB Title V and 57 SGB Title XI. BARMER stores these data for 9 years.
[Lebenspartnerschaftsgesetz] The data relating to the insurance contract (Sections 288 SGB Title V, 99 SGB Title XI) will be stored
4)
Statement of income on separate form for a maximum of 30 years.
5)
Please attach documentation.
6)
The purpose of this question is exclusively to check possible reimbursement or compensation claims If the legal conditions are met, you are entitled to view this information, to seek correction and
against third parties (e. g. damages resulting from an accident, malpractice, occupational illness – eletion or limitation, and to data portability.
d
Sections 102 et seqq., 116 German Social Code, Title X [SGB]). BARMER stores these data for 6 years
and then deletes them. You may file an objection against the processing of your personal data with us or with the German
Federal Commissioner for Data Protection and Freedom of Information. Our Data Protection Officer
can be reached at [email protected] or at Lichtscheider Str. 89, in 42285 Wuppertal, Germany.
16E 0918
GS-Nummer GS-Nummer Vertriebspartner
Family insurance cover – I hereby apply for We also need details of your spouse even if family insurance cover is
only required for your children. Data is collected under the provisions
free co-insurance from the month of entry of the Fifth Book of the German Social Insurance Code (§§ 10, 284,
289 SGB V) and required in order to provide f amily insurance cover.
for the following family members
Spouse/partner 1) Dependent Dependent Dependent
First name
Last name
Address if different
Date of birth
Maiden name 2)
Place of birth 2)
Nationality 2)
State pension insurance no.
Gender female male female male female male female male
Relationship (please complete: daughter, son,
stepchild, foster child, grandchild, adopted child)
Is the spouse related to the child?
(Please tick only if there is no family relationship) no no no
Previous insurance cover:
ended on:
was with:
(name of health insurance provider)
Type of previous insurance Policyholder Policyholder Policyholder Policyholder
Family insurance cover Family insurance cover Family insurance cover Family insurance cover
Not statutory Not statutory Not statutory Not statutory
Providing there was a recent family insurance First name First name First name First name
policy, last name and first name of the
person who was the policyholder for the
family insurance cover.
Last name Last name Last name Last name
The previous insurance policy is still with:
(name of health insurance fund/
health insurance provider)
Are there any physical
injuries/health impairments? 3) yes no yes no yes no yes no
Type
Are you currently employed
(incl. self-employment)? yes no yes no yes no yes no
If you answer 'yes', please give from/until
dates and answer questions a) to c)
a) r egular gross monthly income
In the case of self-employment:
Please enclose current income tax statement
€ € € €
b) gross earnings from marginal
part-time work € € € €
c) marginal part-time work from/until
Other monthly income as defined by income
tax laws (e.g. retirement pension, retirement
benefits, rent, leases, income from interest) € € € €
Attending school/university from/until
(for children under the age of 23, please
attach certificate or submit later)
Type of school/university
(e.g. Hauptschule, Realschule, Gymnasium) 4)
Class/No. of semesters 4)
Military/civilian service from/until (please
attach certificate of service or submit later)
I will inform you of any future changes immediately. This is of particular importance if the gross income of the family dependents listed above increases or if one of these dependents takes out a
olicy with a (different) health insurance fund. In signing this document, I confirm that my dependents agree to submit the required details. In the case of family dependents who live separately
p
from the policyholder, either the policyholder or this family member can sign.
Date Signature Signature of family members over the age of 15
1)
ame-sex partnership as defined by the law governing civil partnerships (Lebenspartnerschaftsgesetz) 2) Only required if no state pension insurance number provided
S
3)
This question is only for checking any claims for reimbursement and compensation against third parties (e. g. damages resulting from an accident, occupational illness) 4) Optional
