General Information HI & PI

General Information - Insurance Application

General Information

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Occupation in Germany

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Health History

Title *

Mr.

Ms.

First Name *

Last Name *

Last Name at Birth *

Nationality *

Date of Birth *

Place/City of Birth *

Country of Birth *

Where did you live before you came to Germany? *

Planned duration of stay in Germany? *

Insurance Start Date *

Email *

Phone Number

Do you already have a German address? *

Yes

Street *

Street Nr *

Postcode *

City *

You are also interested in household contents insurance, please provide the address to be insured *

Same as above

Enter new address

Street *

Street Nr *

Postcode *

City *

Square Meters of Living Space *

Please provide the square meters of living space of the insured home.

Recommended Sum Insured

Family Status *

Married since *

Do you need insurance coverage for your partner as well? *

Yes

Title *

Mr.

Ms.

First Name *

Last Name *

Last Name at Birth *

Place of Birth *

Nationality *

Country of Birth *

Date of Birth *

Is your partner self-employed? *

Yes

Do you have child/ren? *

Yes

How many child/ren? *

Do your child/ren live in the same household as you? *

Yes

Do you need insurance coverage for your child/ren as well? *

Yes

Payment Information (optional)

Name of Account Holder

IBAN

BIC

Additional Notes