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Personal information (*required fields)

salutation*

Title

First name *

Surname *

Street and house number *

Postcode *

Town *

Date of Birth *

Telephone number

Email *

Your preferred start date of insurance

at the earliest possible date or at the

Do you want to co-insure family members free of charge?

Yes

Yes, I would like to co-insure my child(ren)

Yes, I would like to co-insure my spouse.

Please select your current profession:

Current activity *

Information on the employer/employment agency

Name

Street and house number

Post code

Town

Telephone number

Company number

Start date of employment or receipt of benefits

I was in a previous employment in Germany, already. *

How were you insured so far?

Previous insurance type *

previous health insurance

cancellation status *

Personal information Edit

Salutation

Title

First Name

Surname

Street and house number

Postcode

Town

Birthday

Telephone number

Your preferred start date of insurance Edit

Co-insure family members free of charge Edit

Please select your current profession: Edit

Information on the employer/employment agency Edit

Name

Street and house number

Post code

Town

Telephone number

company number

Start date of employment or receipt of benefits

Previous employment in Germany

Previous insurance Edit

Previous insurance type

Previous health insurance

Cancellation status

Data protection statement

The data is collected and processed for the fulfilment of our tasks according to §§ 284 i. V. m. § 175 SGB V. Your cooperation is required according to § 60 SGB I and § 206 SGB V. Without the necessary data a membership cannot be accomplished. Recipients of your data may be third parties or service providers commissioned by us within the framework of statutory obligations and notification powers. General information on data processing (German) and your rights can be found at www.energie-bkk.de (data protection section). If you have any questions about data protection, please contact datenschutz@energie-bkk.de.

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THANK YOU VERY MUCH FOR YOUR APPLICATION FOR MEMBERSHIP!

Personal information (*required fields)

Your preferred start date of insurance

Do you want to co-insure family members free of charge?

Please select your current profession:

Information on the employer/employment agency

How were you insured so far?

Personal information Edit

Your preferred start date of insurance Edit

Co-insure family members free of charge Edit

Please select your current profession: Edit

Information on the employer/employment agency Edit

Previous insurance Edit