Family Insurance (Englisch) - German WP

Techniker Krankenkasse
20903 Hamburg
Last Name
____________________
First Name
____________________
Street, No.
____________________
Postcode, City____________________
Please choose one of the following options for returning the form
by mail
by fax
by e-mail
Health Insurance No.

________________________________
Please note: The application form needs to be signed by hand.
Non-contributory Dependants Co-insurance

Start date of non-contributory
dependants co-insurance cover
for my spouse/life partner*
Pension Insurance No
Day Month Year
Start date of non-contributory

dependants co-insurance
for my child/children
Please give the following details if your spouse/life partner*

does not have a German Pension Insurance Number yet:
Last Name at birth
Day Month Year

Please indicate a date. If you do not specify a date or indicate
"as of now" this information is not legally valid.
Reason for applying for non-contributory

Place and country of birth

Nationality
Different address, if applicable
Commencement of my own membership
Street, No.
Marriage
Postcode and city
Birth of my child
Previous health insurance of spouse/life partner*
Termination of previous membership

of my dependant
Membership
Other
Non-contributory dependants co-insurance
Marital status
Not covered by statutory health insurance
Married
Separated
Single
Divorced
Widowed
from
Day Month Year
Day Month Year
Health insurance
Registered Partnership*
Non-contributory dependants co-insurance of

membership of:
Last Name, First Name
Previous health insurance

Membership
Non-contributory dependants co-insurance
Not covered by statutory health insurance
Health insurance
We need the following details, even if you do not wish to have your
spouse/life partner* co-insured with us.
Last Name
Please enclose marriage certificate if different from member's last name.
First Name
W307001E
yes
no
If so, please answer the following questions for your

spouse/life partner*
Spouse or Life Partner*
Date paid employment

(including mini-job) started
Average monthly gross income
from marginal employment
EUR
Day Month Year
Date self-employment started

Day Month Year
TK Insurance Number,
if applicable
Average monthly profit
Date of birth
Day Month Year
* pursuant to the Lebenspartnerschaftsgesetz
[German Life Partnership Law] (LPartG)
My spouse/life partner*
has a personal income
EUR
Average working hours per week
2 - 04.08.2015
W307001E
Self-employed childminder
yes
no
Other average monthly income EUR
Date Unemployment Benefit II started
Type of income (e. g. income from lease, interest)

Day Month Year
Pensions and related benefits/

company pensions, foreign, national
or other pensions monthly
amount payable
EUR
Please send us a complete copy of your last income tax assessment.
st
1 child
nd
child
Last Name
First Name
Please enclose birth certificate in
case of different last names.
Gender
male
female
male
female
Birth child
Foster child
Birth child
Foster child
Stepchild
Grandchild
Stepchild
Grandchild
yes
no
yes
no
Date of birth or TK Insurance No.

Different address, if applicable:
Street, No.
Postcode and city
Relationship
My spouse/life partner is
child's birth parent
Pension Insurance Number
Please give the following details if
you do not have a Pension
Insurance Number yet:
Last Name at birth
Place and country of birth
Nationality
Previous insurance
Membership
Membership
Non-contributory
Non-contributory
Not covered by statutory

health insurance
Not covered by statutory

health insurance
Period of cover
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Name of health insurance
W307001E
Postcode and city

Average monthly
gross income
EUR
Average monthly
gross income from mini-job
EUR
Monthly profit from

self-employed work
EUR
Self-employment as
childminder
yes
no
yes
no
3 - 04.08.2015
W307001E
Pension and related benefits/

company pensions, foreign, national,
or other pensions;
monthly amount payable
EUR
Other average monthly income EUR
Entitlement to Unemployment
Benefit II
yes
School attendance
Please enclose certificate of school
attendance for children 23 and over.
no
yes
Day Month Year
no
-
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Day Month Year
Type of school (optional information)

Higher education
Please enclose current enrolment receipt

for children 23 and over.
Day Month Year
Day Month Year
Type of university/college
(optional information)
Basic military service or
alternative community service
Please enclose a certificate of service.
Day Month Year
Day Month Year
Contact details
Phone
E-mail
Date
Day Month Year
Signature
Signature of Dependant if applicable
I hereby declare that my dependants have given

their consent to the processing of the required data.
In case you are separated, you have to sign only.
W307001E
S307001E
We need your personal data ("social data") to correctly perform our tasks for you. Based on the Sozialgesetzbuch
(SGB V) [Social Security Code book V], we have legal responsibility to comprehensively protect your personal data.
Your photograph for the electronic health card
Please submit your passport photo (except for insurees

under age 15) so that you get your electronic health card in
time at the beginning of your insurance cover. In case you
do not have a photo at hand, you can send this form
separately.
Please glue your

photo onto here.
Mr
Ms
Last Name
First Name
Date of birth
Day
Month
Year
Health Insurance Number or

German Pension Insurance
Number
Phone number
(optional information)
I hereby certify that this passport photo is a true likeness of me.

Date
Day
Month
Signature
Year
Information on the photograph

It would be best to submit a recent photograph that corresponds to a passport photo. However,
it must not meet the biometric requirements of the new passports. The specifications are as
follows:
approx. 45 mm x 35 mm in size
in colour or black and white
preferably a neutral background
clearly recognisable full face and front view
For internal use by TK

TK-Versichertennummer

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Techniker Krankenkasse

Health Insurance No.

Please note: The application form needs to be signed by hand.

Non-contributory Dependants Co-insurance

Start date of non-contributory

Please give the following details if your spouse/life partner*

Day Month Year

Reason for applying for non-contributory

Place and country of birth

Commencement of my own membership

Postcode and city

Previous health insurance of spouse/life partner*

Termination of previous membership

Non-contributory dependants co-insurance

Not covered by statutory health insurance

Day Month Year

Day Month Year

Non-contributory dependants co-insurance of

Previous health insurance

If so, please answer the following questions for your

Spouse or Life Partner*

Date paid employment

Day Month Year

Date self-employment started

Average monthly profit

Average working hours per week

Other average monthly income EUR

Date Unemployment Benefit II started

Type of income (e. g. income from lease, interest)

Pensions and related benefits/

Please send us a complete copy of your last income tax assessment.

Date of birth or TK Insurance No.

Not covered by statutory

Not covered by statutory

Day Month Year

Day Month Year

Day Month Year

Day Month Year

Name of health insurance

Postcode and city

Monthly profit from

Pension and related benefits/

Day Month Year

Day Month Year

Day Month Year

Day Month Year

Day Month Year

Day Month Year

Day Month Year

Day Month Year

Type of school (optional information)

Please enclose current enrolment receipt

Day Month Year

Day Month Year

Day Month Year

Day Month Year

Signature of Dependant if applicable

I hereby declare that my dependants have given

In case you are separated, you have to sign only.