Introduction	In brief	flyer	online application	FAQs

Gesetzliche Krankenversicherung - - Statutory health insurance for employees

Statutory health insurance - - Statutory health insurance for employees

online application

Instructions on completing the form

After you have filled out and sent the online form, you will receive a printable declaration page (Versicherungsschein) by e-mail, assuming all information is complete and valid.

Help: auxiliary information you will find touching the next to the respective fields.

Enabling JavaScript is required for the application form to work. Below you get specific instructions on enabling JavaScript in your browser. If your browser isn't listed, please consult its help resources.

Internet Explorer 6.0+

Click the Tools menu.
Select Internet Options.
Click the Security tab.
Click the Custom Level button.
Scroll down until you see the 'Scripting' section. Select the 'Enable' radio button for 'Active Scripting.'
Click the OK button.
If you see a confirmation window, click the Yes button.

Firefox 3.6+

Click the Tools menu.
Select Options.
Click the Content tab.
Select the 'Enable JavaScript' checkbox.
Click the OK button.

Policyholder / Insured person

Salutation

First name

Last name

Date of birth

Age

Nationality

Has the insured person had their permanent residence in Germany or Austria for at least two years? Yes No

Additional information policyholder/ Insured person

Place of birth

Policyholder’s address/Contact information

Do you already have an address in Germany? Yes No

Additional questions on statutory health insurance

Where are you employed? (employer’s company name)

Street building no.

Postal code

City

income

When does/did your employment begin?

Social insurance number (if available)

Do you want to include your family members into the insurance? Yes No

Information about health insurance

Insurance plan DAK - Statutory health insurance for employees

Additional contact information in the event of questions

e-mail

Area code*

Telephone*

Fax no.*

How did you find us?*

Tipp for qq-user:
To be sure that you receive all documents, please fill in another (not qq-)e-mail in the field for the second e-mail

You can enter an additional e-mail-address here, to which we will also send the insurance documents.*

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.

Referrer / agent number

Terms and conditions health insurance

By clicking on the adjoining field you confirm that you have read, understood and agreed to the following conditions. Versicherungsschutz soll über die DAK - Deutsche Angestellten Krankenkasse - bestehen. At the same time you are confirming that you have printed and / or downloaded the following conditions:

Gesetzliche Krankenversicherung Information x

Insurance type:

Insurable persons:

Entry age:

Premium from

Duration:

Benefits*

*For a complete list of benefits see the general insurance conditions (GTI).

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