Please provide us with the following information so that we can offer you the best package appropriate to your desires and needs.

Applicant

Note: You must be 18 years or older to open a blocked account

Date of birth (dd.mm.yyyy)

Nationality

Information about your stay in Germany

Which country do you currently live in?

Requested start date of the visa (dd.mm.yyyy)

If the exact date of entry/departure (start of the trip) is not known, please select the anticipated date of entry/departure.It is possible and easy to postpone the commencement of coverage in writing (via customer portal, mail, fax or email) before the coverage begins.

Why are you coming to Germany?

Information about Blocked Account

I have US citizenship or a Green Card. Yes No

I am liable for tax in the USA Yes No

Blocked Amount per month

The usual monthly blocking amount is currently €992.00. This amount may vary, please enter the amount specified by the embassy or consulate.

Until what date is your visa going to be valid? (dd.mm.yyyy)

Duration

Here you can see the duration in months resulting from your chosen visa expiry date. From the start date of your visa, you can select a maximum of 12 months here.

Health-related questions

These are the health related questions of the insurer according to § 19 V VVG.

I confirm that I have given all information completely, carefully and correctly. In addition, I am entitled to make all declarations/statements and am fully informed of their submission. Should this not be the case at any point, I have made this clear.
To the best of our knowledge, all in the application requested information must be answered carefully, completely and correctly. A breach of your pre-contractual duty of disclosure may entitle Advigon Versicherung AG to withdraw from the contract, terminate the contract or amend the contract. Please note the separate notification according to § 19 Abs. 5 VVG about the consequences of a violation of the legal duty of disclosure (PDF file).

Height of the person to be insured in centimeters (cm) cm

Body weight of the person to be insured in kilograms (kg) kg

1. Have complaints, illnesses, health problems, anomalies and/or the consequences of accidents existed in the last 3 years or still existing (except regular check-ups without findings, common colds/flus or short-term, minor gastro-intestinal diseases)? Yes No

2. In the last 3 years, have treatments by doctors/associates of other healing professions (e.g. dentist, alternative practitioner, psychotherapist / psychologist) been carried out on an outpatient basis or in hospitals / health resorts or are such treatments recommended for the future? Please do not indicate any preliminary examinations in which no findings have been made. Yes No

3. Have you taken any medication (other than contraceptives) regularly for more than 14 days in the past 12 months? Yes No

4. Are there missing teeth in the natural teeth that have not yet been replaced? If yes, please indicate the number. (Complete closure of gaps, wisdom and milk teeth are not considered missing teeth) Yes No