Step 1: Fill in the form with personal details and health data about the person to be insured

Step 2: (If necessary): Health questionaire for the person to be insured

Step 3: Fill in the form with address details and insurance details

Step 1:

A link to step 2 (if necessary) (further health questions) or to step 3 (address details and insurance details) will be displayed after completing and submitting this online form. At the same time, we will send you an e-mail containing this link.

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Person to be insured

Salutation

First name

Last name

Date of birth (dd-mm-yyyy)

Entry age

Nationality

Person to be insured: Health questions

Health questions

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 HanseMerkur Krankenversicherung AG to withdraw from the contract, terminate the contract or amend the contract. Please note the separate notification according to § 19 Abs. 5 Versicherungsvertragsgesetz 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

Additional contact information in the event of questions

Area code

Telephone

Fax no.

* The fields marked with an * asterisk are not required to take out a policy, but the information provided makes it easier for us to contact you. You will not receive any unsolicited advertising material via email, and we will not forward your information on to any third parties.

How did you find us?

The fields marked with an * asterisk are not required to take out a policy, but the information provided makes it easier for us to contact you. You will not receive any unsolicited advertising material via email, and we will not forward your information on to any third parties.

Information regarding insurance | Show premium table

Premium list private health insurance Care Student

Age	Health insurance for students	Nursing insurance for students^*	Total
12-29 Years	69,62 € / Month	25,97 € / Month	95,59 € / Month
30-39 Years	95,68 € / Month	25,97 € / Month	121,65 € / Month

^*The compulsory nursing care insurance is only due for persons who are subject to compulsory social insurance (e.g. registered students)

Premium list private health insurance Care Student

Age	Health insurance for students	Nursing insurance for students	Total
12-29 Years	69,62 € / Month	25,97 € / Month	95,59 € / Month
30-34 Years	95,68 € / Month	25,97 € / Month	121,65 € / Month

^*The compulsory nursing care insurance is only due for persons who are subject to compulsory social insurance (e.g. registered students)

Insurance plan Care Student

Commencement of coverage (dd-mm-yyyy)

Referrer / agent number

Important statements and documents

By clicking on the adjoining field the applicant and the person to be insured confirm that they have read, understood and agreed to the following important statements and documents . If the applicant and the insured person are not identical, you confirm that you are entitled to make all legal declarations for the insured person by virtue of the same or the law or may make such declarations on their behalf. At the same time, by clicking here you are confirming that you printed and / or downloaded the following terms and conditions/documents before sending your application:

Consent to the collection and use of personal health information and confidentiality release statement
consent according to enclosed declaration point H
Data protection information when applying for the insurance contract consent according to enclosed declaration point D
Data protection information when applying for the insurance contract
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 HanseMerkur Krankenversicherung AG to withdraw from the contract, terminate the contract or amend the contract. Please note the separate notification according to § 19 Abs. 5 Versicherungsvertragsgesetz about the consequences of a violation of the legal duty of disclosure (PDF file).