Mr. Mrs.   (ggfs.Titel) Dr. Prof. Dr.         Nationality:
Family name   Name
Street + house no.
Country:       Zipcode     Town

Tel. No.:   FAX:    
E-Mail:     Date of birth (DD-MM-YYYY):   Gender: male female
Profession:     professional status: please select: employee self-employed
(-> notice: employees or self-employed only - no students. Students: please ask your University)


Marital status: single married
Income per year: Yearly brutto income range (please select): up to 20.000,-- EUR up to 30.000,-- EUR up to 45.900,-- EUR more than 45.900,-- EUR
For how long are you planning to stay in Germany? (note: our insurance contracts are for at least one Year)

-> 2nd part of the form

blank form health insurance in Germany, part 2:



desired insurance treatments:  
stationary treatment: please select: ward, medical on duty (Mehrbettzimmer / diensthabender Arzt) two bed room and treatment from the senior doctor (2-Bettzimmer + Chefarzt) single bed room and treatment from the senior doctor (Einzelzimmer + Chefarzt)
ambulant treatment: please select: standard treatment comfort treatment top treatment   teeth treatment: please select: low refund medium refund high refund
Self contribution ("Selbstbeteiligung"): (..as more self contribution, as less the monthly contribution) optimized fee by self contribution self contribution up to 100,-- EUR p.a. self contribution up to 400,-- EUR p.a. self contribution up to 800,-- EUR p.a. self contribution up to 1500,-- EUR p.a. self contribution more than 1500,-- EUR p.a.
long term disability in case of sickness (financial compensation of income loss, "Krankentagegeld"): please select: none 10,-- EUR 20,-- EUR 30,-- EUR 40,-- EUR 50,-- EUR 60,-- EUR 70,-- EUR 80,-- EUR 90,-- EUR 100,-- EUR 120,-- EUR 130,-- EUR 140,-- EUR 150,-- EUR 160,-- EUR 170,-- EUR 180,-- EUR 190,-- EUR 200,-- EUR 220,-- EUR 240,-- EUR 260,-- EUR 280,-- EUR 300,-- EUR 350,-- EUR   after ("Karenzzeit") please select: 3 days 7 days 14 days 21 days 28 days 42 days 91 days 182 days 365 days
What is most important to you: best relation between price and treatment as cheap as possible high refunds and best treatment

Do You have any previous sickness? Or any other questions or suggestions ?