My Health Insurance Enrolment

My Health Insurance Enrolment
Meine Beitrittserklärung
Start of Membership
Start der Mitgliedschaft
I would like to become a member of the BKK vor Ort
Date Datumdd/mm/yyyy
English Englisch
Ich möchte Mitglied der BKK vor Ort werden.
Ms/Mrs Frau
Surname Name
Mr Herr
Personal data Persönliche Angaben
First name Vorname
Date of birth Geburtsdatumdd/mm/yyyy
Name at birth Geburtsname
Country of birth/place of birth Geburtsland/Geburtsort
Nationality Staatsangehörigkeit
Street Straße
Country Land
House number/additional information Hausnummer/Zusatz
ZIP/Post code PLZ
City Ort
Telephone (daytime) Telefon tagsüber
Please apply for
a social security
number on my
behalf
Telephone (evening) Telefon abends
Email address E-Mail-Adresse
Bitte Rentenversicherungsnummer für mich
beantragen
German insurance number Bundeseinheitl.Versicherten Nr.
Name of bank Geldinstitut
Pension fund number Rentenversicherungsnummer
IBAN IBAN
BIC BIC
Employee Beschäftigter
Self-employed Selbstständiger
Other voluntarily insured person
Trainee Auszubildender
Student Student
Recipient of benefit ‘AL-Geld I
My salary exceeds the annual remuneration limit (EUR 54,900.00 p.a. – effective 2015)
Recipient of benefit ‘AL-Geld II
My monthly gross salary is up to EUR 450.00 (mini job)
Retired Rentner
Basis for insurance coverage Versicherungsgrundlagen
Tax ID Steuer-ID
sonst. freiwillig Versicherter
Mein monatliches Bruttoentgelt beträgt bis zu 450,- Euro (Minijob)
Bezieher v. AL-Geld II
dd/mm/yyyy
Name of employer / job centre / Federal Employment Agency / university Name des Arbeitgebers / Jobcenters / Agentur für Arbeit / Hochschule
Street Straße
Country Land
Employed/registered since beschäftigt/gemeldet seit
House number/additional information Hausnummer/Zusatz
ZIP/Post code PLZ
City Ort
Telephone Telefon
Email address E-Mail-Adresse
I am married Ich bin verheiratet
I have children: Ich habe Kinder:
My spouse/partner is to be covered by my insurance
My children are to be covered by my insurance policy!
Mein (Ehe-)Partner soll bei mir mitversichert werden
Number of children: Anzahl Kinder:
Meine Kinder sollen bei mir mitversichert werden!
My spouse/partner is insured under the following statutory
health insurance plan: Mein (Ehe-)Partner ist gesetzlich versichert bei:
I was last covered by: Ich war zuletzt versichert bei: Name of my last health insurance provider Name meiner letzten Krankenversicherung
Country Land
Insured since versichert seit
City Ort
Compulsory insurance pflichtig
Voluntary insurance freiwillig
Private insurance privat
Not covered by statutory insurance
Insured until versichert bis
Confirmation of cancellation is enclosed
Family insurance familienversichert
Relocation from abroad
Confirmation of cancellation to follow
nicht gesetzl. versichert
Zuzug aus dem Ausland
dd/mm/yyyy
Die Kündigungsbestätigung liegt bei
Die Kündigungsbestätigung wird nachgeliefert
Die Angaben sind zur rechtmäßigen Erfüllung der Aufgaben der Krankenkasse erforderlich; sie werden aufgrund der Vorschriften des
Sozialgesetzbuches erhoben. Ihre Angaben werden streng vertraulich behandelt und unterliegen dem Datenschutz.
Place, date and signature Ort, Datum und Unterschrift
MEMBERS RECRUIT NEW MEMBERS
Ms/Mrs Frau
Mr Herr
dd/mm/yyyy
This information is required by the health insurance company to fulfil its statutory obligations; the information is gathered pursuant to the provisions of the Social Security Act. All information provided will be treated as strictly confidential
and is subject to the Data Protection Act.
✗
Signature Unterschrift
Ich habe eine selbstständige Tätigkeit
Mein Einkommen liegt über der Jahresarbeitsentgeltgrenze (jährlich 54.900,- Euro – Stand 2015)
Bezieher v. AL-Geld I
Civil servant Beamter
I am self-employed
DD D
I was recruited by: Ich wurde geworben von: Self-recruitment Ich werbe mich selbst
Surname Name
First name Vorname
Name of bank Geldinstitut
Date of birth Geburtsdatumdd/mm/yyyy
IBAN IBAN
BIC BIC
The provision of bank details is essential, so we may transfer the referral incentive to your account. The incentive will
be paid once the new membership has been confirmed. All information provided will be treated as strictly confidential
and is subject to the Data Protection Act.
✗
Die Angaben zu Ihrer Bankverbindung sind für die Überweisung der Werbeprämie zwingend notwendig. Die Auszahlung der Prämie erfolgt
nach Bestätigung der neuen Mitgliedschaft. Ihre Angaben werden streng vertraulich behandelt und unterliegen dem Datenschutz.
Place, date and signature Ort, Datum und Unterschrift
SAP-GP no. SAP-GP-Nr.
Health insurance no. Krankenversicherungs Nr.
Employee no. Mitarbeiter-Nr.
E
Mitgliederwerbung 2015_01
Changing over to BKK vor Ort – it’s a piece of cake
1
Fill in the enrolment
form
Please complete this enrolment form in CAPITAL
LETTERS to make sure
that all is legible. Thank
you!
2
Cancel your current
statutory health
insurance
Simply use our pre-printed cancellation form. Your
statutory health insurance
provider is obliged to
confirm such cancellation
within 14 days.
Information about membership of or
cancellation of the statutory health
insurance:
Membership shall generally be for a
minimum period of 18 months. The notice period shall always be two months
to the end of any month.
For example: You cancelled your membership with your former statutory health
insurance provider on 15 October. Your
membership will thus end on 31 December. The period between cancellation
and termination of the health insurance
amounts to two full calendar months:
November and December. You will
become a member of BKK vor Ort effective 1 January.
3
Send the confirmation of cancellation
by your former health
insurance provider to
your BKK vor Ort
You may send the confirmation of cancellation
either together with your
enrolment form or submit
it later.
Did your statutory health insurance
provider raise your additional premium?
In this case, you may cancel your insurance by giving two months’ notice to
the end of any month – even if you have
been a member for less than 18 months.
Important notice: The cancellation must
be received by your health insurance
company in the very month that your
additional premium was raised.
Were you previously insured as a
family member or have you been
uninsured for less than one month?
In this case, you can immediately
change to another health insurance
provider – without giving notice.
4
Your BKK vor Ort
will issue a membership certificate for
you
… and send it to your employer, for example. From
the very first day of your
membership you will be
entitled to all benefits and
can avail yourself of the numerous advantages offered
by your BKK vor Ort.
Very important: Your new electronic
health card (eGK) ...
… will be sent to you once you have
submitted your photo to us. For information on the procedure, please see
our website www.bkkvorort.de (just
enter the webcode 1253).
We can also send you our photo
submission form. Just affix your photo
to this form and return it to our service
provider.
We are always there for you and
your health and will personally
­answer any questions you may
have regarding your membership.
It’s time to change!
Get an incentive of € 20 for recruiting a new member or for self-recruitment!
You may contact us as follows:
BKK vor Ort
Zentraler Posteingang
45064 Essen
Service-Fax: 0234 479 1999
Email: [email protected]
www.bkkvorort.de
2eu0ro
ive
incent
Toll-free service number
0800www.bkkvorort.de
222 12 11