Application for Health Insurance - hc consulting AG
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Application for
Health Insurance
Application to take out an insurance policy
The submission of this application form constitutes a binding application
for the conclusion of an insurance policy on the basis of the terms and
conditions and information relating to the policy which you were provided
with beforehand.
We can accept your application by sending you a certificate of insurance or
a formal declaration of acceptance in advance.
The insurance policy is considered concluded upon receipt.
Your Service Partner:Application for health insurance
with AXA Krankenversicherung AG
21008983 (01.21)
Please complete in block letters
PV AF First application
00 ÖD GM Request for
ZN/VD BD AB Agency No. Org.KZ Motive GSG ZUW Insurance no. SV-VK-Nr. amendment
Foreign key
Applicant/ Mr. Surname First Name Title
Policyholder Mrs.
Street, house number (permanent place of residence) Postcode (permanent place of residence) Town/City (permanent place of residence)
Usual Place of abode (if different from the permanent place of residence) Street, House No. Postcode Town/City
Occupation (precise description), line of business Date of birth (Day/Month/Year) Nationality
Telephone* Facsimile* e-Mail*
* Voluntary information
Private sector Manual worker/employee Civil/public servant (incl. police and fire brigade) Armed forces
Public sector Housewife Healthcare professional Other Freelancer Student/school Pupil
Mandatory to answer for ActiveMe
Mobile phone e-Mail
Identification for ID card (German) Passport (German) Other (for ID numbers of foreign customers
our portals
Identity card number Valid until (day/month/year)
Issuing authority
Digital The policyholder explicitly agrees to digital communication with the insurer, subject to the registration in customer portals. All statements made by the
communication insurer are generally made digitally via AXA‘s customer portals. Excluded from the digital communication, however, are statements by the insurer that have to
be made in writing. The customer is not entitled to demand electronic delivery of all documents. We also use your e-mail address to communicate with you.
Previous insurance Are you/the person to be insured current or previous holders Policy number
with AXA/DBV of health insurance with AXA/DBV/DBV-Winterthur? Yes No
Insurance 1st Applicant Male Female 2nd Applicant Male Female
applicants Name Birth name* (if different from name) Name Birth name* (if different from name)
First name/s (all first names)* First name/s (all first names)*
Date of birth (Day/Month/Year) Place of birth* Nationality Date of birth (Day/Month/Year) Place of birth* Nationality
* Only required when applying from ActiveMe and GEPV tariff (Pflege Bahr)
Professional occupation Professional occupation
Expected apprenticeship/ Day/Month/Year Expected apprenticeship/ Day/Month/Year
traineeship end traineeship end
Expected end of studies Day/Month/Year Expected end of studies Day/Month/Year
Estimated to receive Day/Month/Year Estimated to receive Day/Month/Year
civil service status as of civil service status as of
Private Sector Public Sector Private Sector Public Sector
Manual worker/employee Civil/public servant (incl. police and fire brigade) Manual worker/employee Civil/public servant (incl. police and fire brigade)
Armed forces Housewife Armed forces Housewife
Healthcare professional Other Healthcare professional Other
Freelancer Student/school pupil Freelancer Student/school pupil
Day/Month/Year Day/Month/Year
– self-employed since – self-employed since
– Number of employees subject – Number of employees subject
to social insurance contributions: to social insurance contributions:
Information on We are legally obliged to report to the financial authorities certain personal data for determining tax deductible health and accident insurance premiums
data transfer and (names, contract data, tax identification number, premiums paid and information concerning refunded premiums if applicable). If information on the tax ID is
the tax identifica- not provided, AXA health insurance will obtain the necessary data.
tion number
Applicant/
Policyholder 1st Applicant 2nd Applicant
Tax ID number (11 figure) Tax ID number (11 figure) Tax ID number (11 figure)
– Seite 1 von 11 – 21008983 (01.21)Applicant/ Name First name
Policyholder
Information IBAN BIC
regarding
premium
collection The applicant is the premium payer and the attached/existing SEPA Direct Debit Mandate for the following bank account should be used.
The premium payer is not the applicant and agrees to the direct debit (Please complete the attached SEPA Direct Debit Mandate)
Premium payer
Name First name
Monthly (1st of the month) Monthly (15th of the month) Quarterly Half-yearly Yearly
Inception of Day/Month/Year Day/Month/Year
insurance
Which tariffs 1st Applicant 2nd Applicant
should be Tariffs Premium in EUR Statutory Tariffs Premium in EUR Statutory
covered? surcharge surcharge
1st Applicant–Total 2nd Applicant–Total
* monthly premium less EUR 5 0,00 0,00 * monthly premium less EUR 5 0,00 0,00
sponsorship (Only applies if sponsorship (Only applies if
the GEPV tariff is applied for) the GEPV tariff is applied for)
Total premium for all persons: (including statutory surcharge)
For the Vision B tariff Please observe the supplementary declaration for Public Sector employees (civil servants and workers) and dependants eligible for government allowance
For ActiveMe-U(A) In the event of ametropia EUR 5 surcharge per month (on top) In the event of ametropia EUR 5 surcharge per month (on top)
policy and the EL Exclusion of benefits for optical aids Exclusion of benefits for optical aids
policy series, inclu-
ding EL Bonus-U(A)
Information Is your GP also internist? yes no yes no
regarding your If so, please enter the name and address If so, please enter the name and address
GP for EL tariffs,
incl. EL Bonus-U(A)
Since when have you Month/Year Since when have you Month/Year
been a patient there? been a patient there?
Re. Preferred tariff Preferred tariff
options
For daily sickness Amount of regular monthly gross income (salaried employee)/ Amount of regular monthly gross income (salaried employee)/
allowance tariffs Pre-tax profit (self-employed) in EUR (average over the past 12 Pre-tax profit (self-employed) in EUR (average over the past 12
please state months, please refer to reverse of application) months, please refer to reverse of application)
Weeks Weeks
Right to claim continued Right to claim continued
payment of salary Yes, No payment of salary Yes, No
Prior insurance 1.) Comprehensive health insurance in the last 12 months 1.) Comprehensive health insurance in the last 12 months
cover (please
state the complete Name of Start (day/ End (day/ Name of Start (day/ End (day/
history) the insurer month/year) month/year) the insurer month/year) month/year)
GKV GKV
[statutory [statutory
health health
insurance] insurance]
PKV [private PKV [private
health health
insurance] insurance]
therapeutic therapeutic
care care
No health No health
insurance insurance
Who cancelled or intends to cancel the policy? Who cancelled or intends to cancel the policy?
Policyholder Insurer Policyholder Insurer
Reason for cancellation: Reason for cancellation:
Does or has the policyholder had outstanding premiums Does or has the policyholder had outstanding premiums
with the previous insurer over the last 12 months? yes no with the previous insurer over the last 12 months? yes no
– Seite 2 von 11 – 21008983 (01.21)Applicant/ Name First name
Policyholder
Prior insurance 2.) Nursing-care insurance 2.) Nursing-care insurance
cover (please If not included in health insurance and for therapeutic care If not included in health insurance and for therapeutic care
state the Which companies/care insurance funds have you been insured with so far? Which companies/care insurance funds have you been insured with so far?
complete With German compulsory long-term care insurance still in place (please With German compulsory long-term care insurance still in place (please
history) submit proof) submit proof)
Name of the insurer Name of the insurer
From/until (Day/Month/Year) By (Day/Month/Year) From/until (Day/Month/Year) By (Day/Month/Year)
Insurance Supplementary insurance Supplementary insurance
still in force (e.g. out-patient, in-patient, supp. dental cover, supp. LTD) (e.g. out-patient, in-patient, supp. dental cover, supp. LTD)
Type of insurance Insurer Type of insurance Insurer
Daily allowance cover Daily allowance cover
(e.g. daily hospitalisation allowance (KHT), daily sickness allowance (KT), LTC (e.g. daily hospitalisation allowance (KHT), daily sickness allowance (KT), LTC
allowance (PT) Course of treatment tariff). Please state the daily allowance rate. allowance (PT) Course of treatment tariff). Please state the daily allowance rate.
Type of insurance Per diem allowance Insurer Type of insurance Per diem allowance Insurer
To be answered/ Pension insurance number Pension insurance number
specified only (Benefit number) (Benefit number)
in the case of
applications for Does additional state-sponsored supplementary long-term care insurance Does additional state-sponsored supplementary long-term care insurance
the GEPV tariff (Pflege-Bahr) exist or has an application for such insurance already been (Pflege-Bahr) exist or has an application for such insurance already been
(Pflege-Bahr) submitted to a different insurance provider? Yes No submitted to a different insurance provider? Yes No
Questions 1. Additional questions if non-contributory long-term care insurance is applied for a child. Prerequisite for premium discount. See reverse of application.
regarding the Total income/income limit and additional information regarding compulsory long-term care insurance.
compulsory LTC Total regular monthly income is (see reverse of application)
insurance applied No regular total monthly income No regular total monthly income
for (For children/
adolescent to be Up to 470 EUR Over 470 EUR Up to 470 EUR Over 470 EUR
included in cover)
Questions 2. Additional questions if non-contributory long-term care insurance is applied for the spouse/registered civil partner. Prerequisite for premium
regarding the discount. See reverse of application. Total income/income limit and additional information regarding compulsory long-term care insurance.
compulsory LTC 2.1. At least one spouse/registered civil partner has held continuous compulsory long-term care insurance since 01.01.1995.
insurance applied
for (For co-insured Yes No Yes No
spouses/ 2.2. Further information for the premium discount for the spouse/registered civil partner, if the spouse/registered civil partner is not the person named under
registered civil 1st or 2nd applicant.
partners)
Name of the spouse/registered partner Name of the spouse/registered partner
From/until (DD/MM/YY) Insured by From/until (DD/MM/YY) Insured by
(A valid certificate – see reverse of application- of compulsory long-term care insurance/proof of insurance with another provider – must be submitted).
Regular total monthly income of the spouse/registered partner (see reverse of application) is
No regular total monthly income No regular total monthly income
Up to 470 EUR Over 470 EUR Up to 470 EUR Over 470 EUR
Information Please answer all questions in full and to the best of your knowledge.
regarding Please also quote – for the periods requested – any complaints or illnesses which you may even consider to be insignificant or the significance of which
state of health you are not in a position to judge or which have, in the meantime, healed. Please note that you will jeopardise your insurance cover if the information you
provide is incorrect or incomplete. Any breach of the pre-contractual duty of disclosure can entitle us, depending on fault, to rescind the policy, cancel the
policy or adjust it, which can, under certain circumstances, give rise to the Insurer being released from its obligation to perform also with respect to insured
events which have already occurred. We refer to the special notice according to § 19, para. 5, sentence 1 VVG – German Insurance Contract Act (see reverse)
contained in this application
1st Applicant 2nd Applicant
Height in cm Weight in kg Height in cm Weight in kg
1. Do you wear spectacles or contact lenses or are you advised to wear them?
Yes No Yes No
Please state the dioptres L R L R
2. Have you been examined, received treatment or consultation?
As an outpatient – in the past 3 years? Yes No Yes No
As an inpatient – in the past 5 years?
(for ActiveMe-U (A), in the past 6 years)? Yes No Yes No
Due to psychological or psychosomatic disorders – in
the past 5 years (for ActiveMe-U (A) in the past 8 years)? Yes No Yes No
Is an examination or treatment currently
recommended or scheduled? Yes No Yes No
3. In the course of the last ten years, have any medicines been prescribed, taken or applied for a period of longer than 6 weeks?
Yes No Yes No
4. Are you suffering from illnesses, malfomations, deformities or reductions in capacity of any part of the body or do you have any body implants (not dental
implants) – also if you are not currently receiving treatment for any of the above?
Yes No Yes No
5. Have you been or are you currently addicted to medicines, alcohol, drugs or other intoxicating substances?
Yes No Yes No
6. Have you, in the last 5 years, suffered or are you currently suffering from any disability, injury/illness as a consequence of military service, any reduction in
earning capacity, invalidity, occupational disability or required long-term care?
If so, please enclose documentary evidence of medical findings and/or treatment/care plans.
Yes No Yes No
7. Are you suffering from an HIV infection or are you awaiting a test result?
Yes No Yes No
– Seite 3 von 11 – 21008983 (01.21)Applicant/ Name First name
Policyholder
Only for tariffs 8. Do you have teeth missing which have not yet Yes No Yes No
with dental been finally replaced? How many How many
insurance cover Please state the number.
and optional
tariffs (Complete closure of a gap, wisdom teeth and milk
teeth are not deemed to be missing teeth).
8a. Are you currently undergoing dental or orthodontic treatment or consultation or is such treatment recommended or scheduled?
(If so, please enclose cost estimate)
Yes No Yes No
8b. Do you wear a splint? Yes No Yes No
If, so please state the type of splint: bite splint bite splint
Occlusal splint Occlusal splint
Protusion splint Protusion splint
8c. Have periodontosis, parodontitis, misaligned teeth or an anomaly of the jaw been diagnosed?
Yes No Yes No
Please note: If the answer to at least one of the questions 8, 8a or 8c is „yes“, and a splint is ticked for Question 8b, please note the personal declaration „Dental
Damage“. If one of the Special Agreements contained therein applies to the requested policy and the answer to the question, the Personal Decla-
ration „Dental Damage“ included in this application must be completed, and the consent of the Customer must be obtained.
Explanation It is important to describe the details as accurately as possible. Always state the nature and scope of any possible consequences or additional medical
of questions treatment requirements! Where there is not enough space, the required details must be specified on a separate sheet of paper to be signed by the
answered Applicant and any other person(s) to be insured under the policy and enclosed with the application.
affirmatively,
quoting
the Applicant
in question and Re. Treatment Nature Unable Examinations, treatment or consulta-
the question Ques- received of to tions which have been conducted, are Medical implications? Are you awaiting
number(s) tion Precise description of illness (diagnosis), nature from – to treatment work recommended or scheduled (please examination results?
no. of complaints, body implants (Day/Month/Year) Out-P In-P Yes No state medicines) If so, what type?
1st Applicant
2. Applicant
Information re. Insured Re. question Name and exact address of the doctor/dentist
doctors/dentists Person no. or other service provider in the health care system Specialist field
and other service
providers in the
health care
system
Comments/
Agreements
Consent to the collection and usage of health data and declaration of release from the duty to maintain confidentiality*
The provisions of the German Insurance Contract Act, the EU data protection ordinance, of the Federal Data Protection Act and other data protection regu-
lations do not contain any sufficient legal bases for the collection, processing and usage of health data by insurance companies. In order to collect and use
your health data for thisapplication and for the policy, we, AXA Krankenversicherung AG, therefore require your declaration(s) of consent regarding data
protection. In addition, we require your release from the duty to maintain confidentiality in order to be permitted to obtain health data from entities which
must maintain confidentiality, from doctors for example. As a health insurance company we also require your release from the duty to maintain confidenti-
ality in order to be permitted to pass your health data or other data protected according to § 203 of the German Penal Code (Strafgesetzbuch), such as, for
example, the fact that a policy has been concluded with you, to other entities, for example, assistance companies, IT service providers or to the Association
of Private Health Insurers. You are at liberty to decline to submit the declaration of consent/release from duty of confidentiality or to revoke them at any point
hereafter with effect for the future. The revocation is to be forwarded to: AXA Krankenversicherung AG, 50592 Cologne, or by fax to +49 (0)221 148 36 202, or
by email to info@axa.de. We would however like to point out that as a rule the completion or implementation of the insurance contract will not be possible
if the health data has not been processed.
The declarations concern the handling of your health data and other data protected by § 203 of the German Penal Code
– by AXA Krankenversicherung AG itself (under 1),
– in connection with enquires made with third parties (under 2),
– for communication to entities outside of AXA Krankenversicherung AG (under 3) and
– if the policy is not concluded (under 4).
The declarations apply to those persons you legally represent such as your children, insofar as these do not realise the consequences of this declaration and are
therefore not in a position to submit their own declarations.
– Seite 4 von 11 – 21008983 (01.21)1. AXA Krankenversicherung AG – collection, storage and usage of the health data you provide
I hereby consent to AXA Krankenversicherung AG acquiring, storing and using the data supplied by me in this application insofar as this is required for the
examination of the application and also for the substantiation, management or termination of this insurance policy.
I hereby consent to AXA Krankenversicherung AG, insofar as beneficial conditions are granted on the basis of co-operations with statutory health insurance
providers, associations, organisations, companies or other third parties, for the purpose of examining whether a corresponding membership or affiliation
with a right to claim beneficial conditions exists, to compare data with the named third parties and I hereby release the insurer in this respect from its duty
to maintain confidentiality.
1.1. Collection, processing and usage of information you have provided regarding trade union membership
I consent to the collection, processing and usage of the information I have provided concerning trade union membership insofar as this is required for the
examination of the application and for the substantiation, management or termination of the policy, in particular for the calculation of my insurance premium.
2. Request for health data from third parties
2.1. Request for health data from third parties for the purpose of risk assessment and for the examination of the obligation to honour a claim.
In order to appraise the risks to be covered it may be necessary to make enquiries with entities which hold your health data. In addition, in order to appraise the
obligation to perform we may have to examine information regarding your state of health upon which you have based your claims or which arise from documents
submitted (e.g. invoices, prescriptions, medical appraisals) or information provided, for example, by a doctor or other member of a medical profession.
Any such examination will only be conducted where required. To render this possible we require your consent, including a release from the duty to maintain
confidentiality, for us and for the respective entities in the event that, within the scope of such enquiries, health data or other information protected pursuant
to § 203 of the German Penal Code has to be communicated.
We will inform you in each individual case regarding the persons or establishments we require information from and for what purpose. You may then decide in
each case whether you
• wish to procure the required documents yourself.
• or consent to the collection and usage of your health data by AXA Krankenversicherung AG, release the named persons or establishments and their employees
from the duty to maintain confidentiality and consent to the communication of your health data to AXA Krankenversicherung AG.
2.2. Declarations in the event of your death
In order to examine the obligation to perform, it may be necessary to examine health information also after you have passed away. An examination may also
be required if, within ten years of conclusion of the policy, concrete evidence emerges that information provided at the time of submission of the application
was incorrect or incomplete and thereby influenced the risk assessment. For this eventuality also, we shall require a declaration of consent and release from
the duty to maintain confidentiality.
Insofar as we have to collect health data after your death, we shall obtain the declarations of consent and the release from the duty to maintain confidentiality-
from your heirs or – in the case of alternative provisions – from the beneficiaries of the policy.
3. Communication of your health data and other data protected pursuant to § 203 of the German Penal Code to entities outside of AXA Krankenversicherung AG.
AXA Krankenversicherung AG binds the following entities contractually to observe the regulations governing data protection and data security.
3.1. Communication of data for medical appraisal
It may be necessary to appoint a medical appraiser to examine the risks to be covered and to assess the obligation to honour a claim. We require your consent
and release from the duty to maintain confidentiality if, in this context, your health data and other data protected pursuant to § 203 German Penal Code is
communicated. You shall be informed of any respective communication of data.
I hereby consent to AXA Krankenversicherung AG communicating my health data to medical appraisers insofar as this is necessary within the scope of the risk
assessment or an examination of the obligation to perform and that such data is used expediently and the results are communicated back to AXA Kranken-
versicherung AG. With regard to my health data and other data protected pursuant to § 203 of the German Penal Code, I hereby release the employees of AXA
Krankenversicherung AG and the medical appraisers from their duty to maintain confidentiality.
3.2. Transfer of tasks to other entities (companies or persons)
We do not carry out certain tasks ourselves such as, for example, risk assessment, claims processing or operating the customer call centre, which max involve the
collection, processing or usage of your health data; we commission another company of the AXA Group or another entity to carry out this work and provide such
services. If your data protected pursuant to § 203 of the German Penal Code is communicated in this connection, we require your release from the duty to maintain
confidentiality for our company and for the other entities where required.
We keep a continually updated list of the entities and categories of entities which, according to the agreement, collect, process or use health data on our behalf,
stating the assigned duties. The currently applicable list is attached as an appendix to the declaration of consent. A current list can also be called up via the
Internet under www.axa.de or requested from your service partner named in your policy documents. We require your consent to communicate your health data
and for such data to be used by the entities named in the list.
I hereby consent to AXA Krankenversicherung AG communicating my health data to the entities named in the list referred to above and to the collection,
processing and usage of my health data by those entities for the designated purposes and to the same extent as AXA Krankenversicherung AG is permitted
to do so. Where required, I hereby release the employees of the AXA group of companies and other entities from their duty to maintain confidentiality with
regard to the communication of health data and other data protected pursuant to § 203 of the German Penal Code.
3.3. Communication of data to reinsurers
In order to secure the fulfilment of your claims, we may involve reinsurers which assume the risk either partially or in full. In some cases, the reinsurers transfer
risks to other reinsurers, to whom your data is also communicated. It is possible that we may present your application for insurance or claim to the reinsurer to
enable the reinsurer to gain its own impression of the risk or the claim. This is common practice in cases where the sum insured is particularly high or if a risk is
particularly difficult to classify.
In addition, by virtue of its expert knowledge, a reinsurer may be called upon to assist us with the assessment of a risk or claim and with the appraisal of
processes.
Where reinsurers have undertaken to cover the risk, they may check whether we have appraised a risk or a claim correctly.
In addition, data relating to your existing policies and applications is communicated to reinsurers to the extent required to enable them to examine whether
and to what extent they can participate in the risk. Data relating to existing policies may be communicated to reinsurers for the purpose of settling premium
payments and claims.
Data communicated for the above-named purposes is anonymous or under a pseudonym wherever possible, but personal data may also be used.
The reinsurers use your personal data only for the aforementioned purposes. We shall inform you of any communication of your health data to reinsurers.
I hereby consent to the communication of my health data – where required – to reinsurers and their usage thereof for the designated purposes.
Where required, I hereby release the employees of AXA Krankenversicherung AG from their duty to maintain confidentiality with regard to the health data
and other data protected pursuant to § 203 of the German Penal Code.
3.4.Exchange of data with the Hinweis- und Informationssystem (HIS) – the German reference and information system for the insurance industry
For the purpose of more exact risk and claim appraisal the insurance industry uses the Hinweis- und Informationssystem (HIS) - the German reference and
information system for the insurance industry, which is currently operated by Informa Insurance Risk and Fraud Prevention GmbH, Rheinstraße 99, 76532
Baden-Baden, www.informa-irfp.de). We can report any peculiarities which may indicate insurance fraud and increased risks to the HIS. We and other insurance
providers retrieve data from the HIS within the scope of the risk or claim appraisal if there is a justified interest to do so. This doesnot involve the communication
of health data, but in order to be permitted to communicate your data protected pursuant to § 203 of the German Penal Code we require your release from the
duty to maintain confidentiality. This applies irrespective of whether the policy is concluded with you or not.
I release employees of AXA Krankenversicherung AG from their duty to maintain confidentiality insofar as they report data from the application or claim ap-
praisal to the respective operator of the Hinweis- und Informationssystem (HIS) - the German reference and information system for the insurance industry.
To the extent required for the appraisal of the duty to indemnify, the HIS system serves to identify insurance providers you have been in contact with in the past
and which may have relevant information at their disposal. Data required for the further examination of claim can be requested from these insurance providers
(see under section 2)
– Seite 5 von 11 – 21008983 (01.21)3.5. Forwarding data to independent intermediaries
As a matter of principle we do not forward any information regarding your heath to independent intermediaries. However, in the following cases it is possible
that data from which conclusions regarding your health can be drawn, or information protected pursuant to § 203 of the German Penal Code is communicated
to intermediaries through your policy.
To the extent required for policy-related consultation purposes, the agent looking after you can receive information regarding whether and possibly under
what preconditions (e.g. acceptance with risk loading, exclusion of particular risks) your policy can be accepted.
The intermediary who mediates your policy learns that the policy was concluded and the content thereof. In doing so he also learns whether risk loadings or
the exclusion of particular risks were agreed.
In the event of a change in the intermediary responsible for you to another intermediary, policy data containing information regarding existing risk loadings and
the exclusion of particular risks may be communicated to the new intermediary. In the event of any change in the intermediary who looks after you to another
intermediary you will be informed prior to the forwarding of health data and you will be advised of your possibilities to object.
I hereby consent that AXA Krankenversicherung AG may, in the above-named cases, communicating my health data and other data protected pursuant to
§ 203 StGB – where required – to the independent intermediary responsible for my insurance affairs and that such data may be collected, stored and used
for consultation purposes.
This consent applies accordingly to data processing by broker pools or other service providers (e.g. operators of comparison software, broker administration
programmes) which my intermediary involves in the conclusion and administration of my insurance policies. I can request my intermediary to provide
information regarding the respective service providers
4. Storage and usage of your health data if the policy falls through
If the health insurance policy falls through, we shall store your health data acquired for the risk assessment in case you reapply to take out insurance cover.
In addition, it is possible that we may provide a reference concerning your application to the (HIS) - the German reference and information system for the
insurance industry, which is communicated to enquiring insurance providers for the purpose of their appraisal of risks and claims (see section 3.4). We also
store your data in order to respond to any enquiries made by other insurance providers. Your data is stored by us and in the HIS until the end of the third
calendar year following submission of your application.
I hereby consent to AXA Krankenversicherung AG storing and using my health data - in the event that the policy falls through - for a period of three years
from the end of the calendar year in which I submit my application for the aforementioned purposes.
5. Forwarding data to credit agencies
It is generally required that credit checks are carried out when processing applications, contracts and payments in order to protect the best interests
of the insurance community. We are assisted in this by other companies from the AXA group or a credit agency. Further information on credit checks
can be found in the section ‘Information on how your data is used’. Ongoing information on your payment behavior is necessary to continually improve
these credit checks, such that we forward appropriate data subject to the declaration of consent below, regardless of whether a specific contract or
benefit has been agreed upon.
I consent to my personal data being used to optimise credit check criteria, with respect to the principles of data economy and data avoidance, where-
by the insurer forwards information on my payment behaviour in general to a credit agency (e.g. SCHUFA). I hereby release the persons employed by
AXA Krankenversicherung AG from their duty of confidentiality regarding data protected as per Paragraph 203 of the Criminal Code – Strafgesetzbuch)
We make explicit reference to the fact that such consent for forwarding data to credit agencies is not required for conclusion and implementation of the
insurance contract. Furthermore, details regarding the voluntary and immediate revocation of the declaration of consent can be found at the start of
this section.
Issued I have received the product information sheets, policy information, the Applicant’s signature – where applicable as the legal
documents insurance terms and conditions for the tariffs applied for. representative of any other persons covered by the insurance.
I request the terms and conditions of insurance to be provided to me
once again with the certificate of insurance.
✗
Important for Please check that the details and declarations you write, or the intermediary writes for you, in this application or in other documents are correct and complete,
applicant and otherwise you could jeopardise your insurance cover. Before you sign this application, please also read the explanations and information on the reverse of
persons to be this application form. These contain, among other things, also the consent to the collection of information regarding your general payment record and your
insured ability to pay and your customer relationship. With you signature you make these declarations a constituent part of the policy.
I have been informed of my statutory right of withdrawal according to the instructions printed on the reverse.
Information General information on the usage of your data and your rights in this regard are set down under the section “Information concerning the usage of your
concerning the data”.
usage of your data
State-sponsored For the state-sponsored supplementary long-term care and attendance insurance (Pflege-Bahr) I hereby irrevocably authorise AXA Krankenversicherung
supplementary AG to apply for the allowance and for the allowance number if such a number has not yet been assigned. In this connection I consent to the insurer
long-term care communicating my personal data to the central pension allowance authority (Zulagenstelle).
and attendance In addition I confirm that I fulfil the eligibility requirements. These are:
insurance
(Pflege-Bahr) 1. I hold compulsory long-term care insurance with a German social or private long-term care insurance provider. I shall inform AXA Krankenversicherung
immediately if I leave the compulsory long-term care insurance scheme.
2. I am over 18 years of age.
3. I do not receive any benefits from state or private long-term care insurance, and have not in the past. Applicable benefits are furthermore not in abeyance
because I am, or have been, primarily in receipt of benefits from other state/public funding agencies, for example from statutory accident insurance.
Declaration of commitment
I furthermore undertake to advise without delay of any change in circumstances regarding the requirements governing eligibility for insurance or funding, in
Issued particular the termination of insurance under state or private long-term care insurance.
documents
I am aware that incorrect information even given unwittingly will result in paid benefits being reclaimed and in rescindment of the contractual relation-
ship, and that any claims arising from the contract will therefore be forfeit.
Insofar as a state-subsidised occupational pension insurance in the meaning of a Riester Rente has been concluded within the AXA Versicherung AG Group
to my benefit or the benefit of the other persons to whom insurance cover will be extended, I hereby authorise AXA Krankenversicherung AG to obtain the
benefits number from this source.
Waiver of the wai- No qualifying period for positive medical examination under the VARIO long-term care insurance tariff.
ting period in the In the case of state-sponsored supplementary long-term care insurance tariff GEPV, AXA shall waive qualifying periods according to § 5 MB/GEPV.
GEPV insurance This presupposes that the health questions applicable to the VARIO long-term care tariff have been answered truthfully, the outcome of the medical
plan (Pflege-Bahr examination is positive and conclusion of the VARIO tariff is not rejected.
[nursing care
insurance]) I am aware that the qualifying periods under the long-term care GEPV tariff applied for simultaneously shall only be waived if these preconditions are fulfilled.
I shall receive confirmation of the waiver of qualifying periods from AXA once again when it issues the certificate of insurance.
Signatures It is hereby confirmed that the application was signed in Germany
(apply also to the
authorisation/ Date (Day/Month/Year) Intermediary‘s signature/Name and Stamp
declaration
relating to the
GEPV tariff
(Pflege Bahr) Signature of the applicant, policyholder or if applicable legal representative
✗
Signature of all other persons to be co-insured hereunder with reference
✗
and, where required, the signature of the legal representative of the
✗ ✗
to all of the above declarations (only for persons age 16 or over) persons to be insured
– Seite 6 von 11 – 21008983 (01.21)Additional declaration for Public Sector employees
(Civil servants and employees) and their relatives who are eligible for Beihilfe
(German government-funded assistance hereinafter referred to as “assistance”)
Applicant/ Name First name
Policyholder
Marital status/ 1st Applicant 2nd Applicant
Information Single Married Widowed Divorced Single Married Widowed Divorced
regarding the Employer Employer
claim to
assistance
Assistance status*) 1st insured Eligibility regulation**) VP 1 Assistance status*) VP 2 Eligibility regulation**) VP 2
Information re. *)**): Please use the indicators which we have presented at the end of this supplementary declaration.
Number of persons eligible for assistance Number of persons eligible for assistance
(Persons eligible and who can be considered for assistance) (Persons eligible and who can be considered for assistance)
Changes to/cessation of assistance in Month Year Changes to/cessation of assistance in Month Year
the case of requirement adjustments the case of requirement adjustments
Only for German If you are entitled to cover from Krankenversorgung der Bundesbahnbeamten If you are entitled to cover from Krankenversorgung der Bundesbahnbeamten
national rail (KVB), please answer this question: (KVB), please answer this question:
officials and their
family members What is the scope of your claim tariff benefits provided by the KVB? What is the scope of your claim tariff benefits provided by the KVB?
I have a full claim to benefits provided by the KVB tariff. I have a full claim to benefits provided by the KVB tariff.
I have a partial claim to benefits provided by the KVB tariff (e.g. because I I have a partial claim to benefits provided by the KVB tariff (e.g. because I
am a civil servants outside of the GFR with an own claim to state aid apart am a civil servants outside of the GFR with an own claim to state aid apart
in addition to the health scheme of the KVB or because I, as a GFR official, in addition to the health scheme of the KVB or because I, as a GFR official,
am no longer a member of the KVB health scheme). am no longer a member of the KVB health scheme).
Soldiers/short- Please inform us of the duration of your commitment (e.g. SaZ 8) Please inform us of the duration of your commitment (e.g. SaZ 8)
term career
soldiers
and the commencement of your commitment as and the commencement of your commitment as
(Day/Month/Year) (Day/Month/Year)
a short-term career soldier a short-term career soldier
Deployment Have you in the last 12 months prior to the application been deployed Have you in the last 12 months prior to the application been deployed
abroad/ Activity abroad or employed/occupied abroad in a foreign area of conflict with abroad or employed/occupied abroad in a foreign area of conflict with
abroad political/warlike conflicts? political/warlike conflicts?
Yes No Yes No
Where? From (DD/MM/YY) Until (DD/MM/YY) Where? From (DD/MM/YY) Until (DD/MM/YY)
Have you already participated in a debriefing seminar? Have you already participated in a debriefing seminar?
Yes No Yes No
What was the outcome? (e.g. further Is a debriefing seminar planned? What was the outcome? (e.g. further Is a debriefing seminar planned?
consultations/treatment/no further Yes No consultations/treatment/no further Yes No
measures required). measures required).
If so, when? If so, when?
Conversion I agree that, in the event of changes to the law governing Beihilfe – German government-funded assistance, my policy shall be converted appropriately
service tariff within the scope of the tariffs available for sale. I may revoke my participation at any time. I shall have the right to demand that policy conversions
group B and effected within the scope of the conversion service are rescinded within one month of receipt of notification of the conversion.
Vision B
Yes No Yes No
Personal I hereby declare the following I hereby declare the following
declaration Name, first name of the person to be insured Name, first name of the person to be insured
for the
conclusion of the
AWFH tariff is a student or college graduate (university, technical college, polytechnic) is a student or college graduate (university, technical college, polytechnic)
(only applies to with the aim to have a career in the civil service as a teacher or professor and with the aim to have a career in the civil service as a teacher or professor and
trainee teachers is currently covered by a German statutory health insurance provider (SHI) is currently covered by a German statutory health insurance provider (SHI)
and teachers under family insurance including LTC cover. under family insurance including LTC cover.
after completion of
teacher training)
Personal I hereby declare the following (please tick appropriately) I hereby declare the following (please tick appropriately)
declaration Name, first name of the person to be insured Name, first name of the person to be insured
upon
conclusion of the
tariff Vision B or Non-smoker Smoker Optical aids Non-smoker Smoker Optical aids
Vision B-N and
Vision B-U, BN3 A person is classified a non-smoker if, in the last 12 months before conclusion of the contract, he or she has refrained from the consumption of tobacco/
and BN3/1-N and nicotine either using e-/cigarettes, cigars, pipes, tobacco heating devices or by other means, and does not intend to do so in the future. As a smoker or
BN3/1-U, consumer of tobacco/nicotine, I agree to a surcharge on the premium for the tariffs VISION B, Vision B-N and Vision B-U. From the age of 16 this amounts to 17%
BN3/2-N and of the tariff premium under the Vision B-U tariff; under the tariffs Vision B and Vision B-N it is 15% for female and 20% for male insureds. I am aware that this
BN3/2-U, BN4, surcharge will be adjusted accordingly if premiums have to be adjusted.
BN4-N,
BN-HF-UZ If I become a consumer of tobacco or nicotine after conclusion of the contract, I hereby undertake to inform the insurer immediately in this regard. I agree that
the surcharge applicable to me will be charged from the time I become a smoker.
21013909 (01.21)Applicant/ Name First name
Policyholder
For my optical aid I agree to a fixed amount on top of the tariff premium Vision B/Vision B-N/Vision B-U and – where applied for – on the tariff BN3,BN3/1-N, BN3/1-U,
BN3/2-N, BN3/2-U, BN4, BN4-N. The amount is the same for children, teenagers and adults - per person under the tariff:
Tariff Tariff Tariff Tariff
Vision B, Vision B-N, Vision B-U BN3, BN3/1-N, BN3/1-U, BN3/2-N, Vision B, Vision B-N, Vision B-U BN3, BN3/1-N, BN3/1-U, BN3/2-N,
BN3/2-U, BN4, BN4-N, BN HF-UZ BN3/2-U, BN4, BN4-N
with the following listed rates of reimbursement/tariff supplements: with the following listed rates of reimbursement/tariff supplements:
00 7.00 EUR 30 15 2.10 EUR 30 0.56 EUR
50-U, 50T, 50-NT, 35 20 2.45 EUR 35 0.52 EUR
50T-U 3.50 EUR 50 0.40 EUR 35 2.45 EUR 35 0.52 EUR
30 2.10 EUR 30 0.56 EUR 40 25 2.80 EUR 40 0.48 EUR
20 1.40 EUR 20 0.64 EUR 40 2.80 EUR 40 0.48 EUR
15 1.05 EUR 15 0.68 EUR 45 30 3.15 EUR 45 0.44 EUR
20 15 1.40 EUR 20 0.64 EUR 45 3.15 EUR 45 0.44 EUR
25 15 1.75 EUR 25 0.60 EUR 50 35 3.50 EUR 50 0.40 EUR
25 1.75 EUR 25 0.60 EUR 50 3.50 EUR 50 0.40 EUR
BN-HF-UZ 0.80 EUR
(Examples: The optical aid surcharge in the tariffs are as follows: Vision B30-N and Vision B30-U = EUR 2.10, tariff BN3/1 30-N and BN3/1 30-U = EUR 0.56,
tariff Vision B 50-NT and Vision B50T-U = EUR 3.50, tariff BN3/2 50-N and BN3/2 50-U = EUR 0.40).
Premium surcharges/fixed amounts are not imposed during a deferred benefit insurance period.
Important for Under certain conditions Private Health Insurance (PHI) enables civil servants, civil service beginners (but not civil service candidates) and their dependants
applicant and to gain easier access to full cover health insurance which complies with state aid through so-called launch campaigns (additional information is available
persons to be on the website of the „PKV-Verband“ (Association of German PHI providers) https://www.pkv.de/service/broschueren/). This facilitated access means com-
insured pulsory acceptance and not an agreement of exclusions from benefits as well as the limitation of loadings to compensate increased risks to 30% (maximum)
of the tariff premium. If your application is to be processed on this basis , and if it is submitted within six months of an access-authorising event (e.g. granting
of the status of a civil servant candidate or probationary official), please state this separately on the Application (e.g. in the section „Comments/Agreements“).
Please note that access via the opening special offers may also be disadvantageous since only certain policies of group-B insurance plan are allowed (You are
welcome to inquire about them with AXA/DBV). If a corresponding note is missing from the Application , or if an Application is made for policies that are not
allowed for the opening special offers, we assume that you do not want or cannot make use of this option.
Signatures It is hereby confirmed that the supplementary declaration was It is hereby confirmed that the supplementary declaration was
signed in Germany signed in Germany
✗ ✗
Date (Day/Month/Year) Date (Day/Month/Year)
Signature of the Applicant/Policyholder and any person(s) to be included Signature of the Applicant/Policyholder and any person(s) to be included
✗ ✗
in the insurance over the age of 16. in the insurance over the age of 16.
*) Assistance status In the case of Baden-Württemberg: AZ = Employee with allowance
B = Eligible for assistance Civil servant status from 01.01.2013: AZ2 = Employee with allowance/2 children
V = Recipient of benefit B13 = Eligible for assistance A = Employee without allowance
E = Eligible spouse/registered partner E13 = Eligible spouse or registered partner A2 = Employee without allowance/2 children
K = Eligible child V13 = Recipient of benefit EAZ = Employee‘s spouse with allowance
H = (Free) gov.-funded health care H13 = Eligible for health care EA = Employee‘s spouse without allowance
B2 = Eligible for assistance/2 children For the use of a flat-rate allowance KAZ = Child of an employee with allowance
B2-Sa = Eligible for assistance/more than (currently only Berlin, Brandenburg, Bremen, KA = Child of an employee without allowance
1 child Saxony from 01.01.2013 Hamburg, Thüringen):
H2-Sa = Eligible for health care /more than Bzu = Entitled to allowance WITH subsidy
1 child Saxony from 01.01.2013 Vzu = Benefit recipient WITH subsidy
B3 = Eligible for assistance/formerly Ezu = Admissible spouse/registered signifi-
with at least 3 eligible children+civil cant other
servant status up to 31.12.2012 Kzu = Admissible child
In the case of regular soldiers: B2zu = Entitled to allowance, more than 1 child,
Hbh = Medical welfare beneficiary (after loss of WITH subsidy
medical care more than 1 child or care
recipient)
Hzu = Medical welfare beneficiary (after loss of
medical care without aid/WITH govern-
ment grant)
**) Eligibility regulation Association? “Bundesland” (SchlH., HH, HB, NdS, Bln, NW, Hess, RhlPf, BaWü, Bay, Saar, M-V, Brbg, LSA, Sachs, Thür)? KVB?
21013909 (01.21)Personal declaration for pre-contractual dental damage
ARL-U, AWFH, BN1/1-U(A), BN1/2-U(A), BZ 15-U(A) to BZ 70-U(A),
BN3/1-U(A), BN3/2-U(A), BN HF-UZ(A), Vision B-U(A), Kompakt
Zahn-U(A), Komfort Zahn-U(A), Premium Zahn-U(A), VIA-Reihe
Application Date from for
Insur. number Caseworker Date
Affected teeth Dental formula: Please mark the missing teeth with an f , and teeth requiring treatment with a b.
(left) Your upper jaw (right)
27 26 25 24 23 22 21 11 12 13 14 15 16 17
37 36 35 34 33 32 31 41 42 43 44 45 46 47
(left) Your lower jaw (right)
Special Please mark the applicable agreement!
agreement
1. In the case of up to 5 missing teeth (internal note 5612/5607)
(BN1/1-U(A), BN1/2-U(A), BZ 15-U(A) to BZ 70-U(A))
For the treatment and replacement of the teeth indicated as missing in the dental formula, including all related prosthetic measures, the policy bene-
fits for reimbursable expenses may be claimed only after a waiting period of two years. In the 3rd year after the effective date of the policy, the policy
benefits are provided up to an invoice amount of EUR 525, and in the 4th year after the effective date up to an invoice amount of EUR 1,050. From the
5th year after the policy effective date onwards, the policy benefits are provided. The treatment and replacement of the teeth indicated as missing
in the dental formula, including all related prosthetic measures, are excluded from coverage in the insurance plans BN1/1-U(A) and BN1/2-U(A), if
requested.
2. in the case of up to 5 missing teeth (internal note 5610/5605)
(insurance plan AWFH, Premium Zahn-U(A))
For the treatment and replacement of the teeth indicated as missing in the dental formula, including all related prosthetic measures, the policy
benefits for reimbursable expenses may be claimed only after a waiting period of two years. In the 3. year after the effective date of the policy, the
policy benefits are provided up to an invoice amount of EUR 525, and in the 4th year after the effective date up to an invoice amount of EUR 1,050.
From the 5th year after the policy effective date onwards, the policy benefits are provided. The effective date of the AWFH insurance plan is the time
of switching to a comprehensive health insurance.
In the case of existing insurance plan BN1/1-U(A), BN1/2-U(A), BN3/1-U(A), BN3/2-U(A), or VisionB-U(A), the treatment and replacement of the teeth
indicated as missing in the dental formula, including all related prosthetic measures, as well as the provision of crowns of all kinds, inlays, onlays
and hammered fillings, are excluded from coverage of insurance plans BN1/ 1-U(A) and BN1/2-U (A), BN3/1-U(A), BN3/2-U(A), and/or VisionB-U(A).
3. in the case of up to 5 missing teeth (internal note 5612)
(insurance plan BN3/1-U(A), BN3/2-U(A), BN HF-UZ(A), Vision B-U(A))
It is agreed that the treatment and replacement of the teeth indicated as missing in the dental formula, including all related prosthetic measures,
are excluded from the coverage.
4. in the case of 5 to 6 missing teeth (internal note 2020)
(Insurance plan ARL-U, Komfort Zahn-U(A), Kompakt Zahn-U(A))
The benefits for dental and/or orthodontic treatment (including dentures) are provided per insurance year, the maximum amount depending on the plan.
This regulation is valid until proof of complete restoration of the dentition. This does not apply to treatments that become necessary as a result of an acci-
dent occurring after the conclusion of the contract. Subsequent to this regulation, the policy‘s dental scale applies, taking into account the insurance period
completed thus far. To verify this agreement, a current dental report with dental status must be submitted on the insurer‘s form.
ARL-U, Kompakt Zahn-U(A) EUR 250
Komfort Zahn-U(A) EUR 500
5. in the case of 6 missing teeth (internal note 5612)
(Insurance plan AWFH, BN1/1-U(A), BN1/2-U(A), BZ 15-U(A) to BZ 70-U(A), Premium Zahn-U(A))
It is agreed that the treatment and replacement of the teeth indicated as missing in the dental formula, including all related prosthetic measures, are
excluded from the coverage. In the case of AWFH insurance plan, the agreement applies to the insurance plan chosen when exercising the option.
6. in the case of teeth in need of treatment, including orthodontic/maxillofacial treatment, as well as in periodontal disease (insurance plan ARL-U,
Comfort Dental U (A), Compact Dental U (A)), if it is not a treatment for missing teeth. In this case, the corresponding special agreement for missing
teeth (4.) should be ticked. If only tartar removal, fillings, inlays or root canal treatments (endodontics) have been recommended or are being
treated on an ongoing basis, AXA Medical Insurance, Inc. [AXA Krankenversicherung AG] waives a separate benefit restriction. (internal note 2021)
The benefits for dental and/or orthodontic/maxillofacialtreatment (including dentures) are provided per insurance year, the maximum amount depend-
ing on the plan. This regulation applies until all treatments, including follow-up treatments, have been completed. This does not apply to treatments
that become necessary as a result of an accident occurring after the conclusion of the contract. Subsequent to this regulation, the policy‘s dental scale
applies, taking into account the insurance period completed thus far. To verify this agreement, a current dental report with dental status must be sub-
mitted on the insurer‘s form.
ARL-U, Kompakt Zahn-U(A) EUR 250
Komfort Zahn-U(A) EUR 500
7. for teeth requiring treatment that are not missing or related to orthodontic/maxillofacial surgery care or periodontal disease (for each of these
cases, please select to the relevant special agreement). (internal note 5613)
(Insurance plan AWFH, BN1/1-U(A), BN1/2-U(A), BN3/1-U(A), BN3/2-U(A), BN HF-UZ(A), BZ 15-U(A) bis BZ 70-U(A), Premium Zahn-U(A), Vision B-U(A))
It is agreed that the current or indicated/planned dental treatment, including all related prosthetic measures and the provision of crowns of any
kind, inlays, onlays, hammered fillings and implants, are excluded from the insurance coverage. In the case of AWFH insurance plan, the agree-
ment applies to the insurance plan chosen when exercising the option.
8. in the case of teeth requiring treatment, including orthodontic/maxillofacial treatment, as well as in parodontitis or 1–5 missing teeth (internal
note 5619)
(insurance plan VIA, VIA Med, VIA Plus)
It is agreed that the current or indicated/planned dental/orthodontic treatment, including all related prosthetic measures and the provision of
crowns of any kind, inlays, onlays, hammered fillings and implants, are excluded from the insurance coverage if the option is exercised in the
chosen insurance plans.
21013908 (01.21)9. in the case of malposition of the teeth or jaw (internal note 5803)
(Insurance plan AWFH, BN1/1-U(A), BN1/2-U(A), BN3/1-U(A), BN3/2-U(A), BN HF-UZ(A), BZ 15-U(A) to BZ 70-U(A), Vision B-U(A), Premium Zahn-U(A)
It has been agreed that all treatments for tooth and/or jaw malposition are excluded from the insurance coverage. In the case of AWFH insurance
plan, the agreement applies to the insurance plan chosen when exercising the option.
10. in the case of periodontal disease (e.g. periodontosis, periodontitis, etc.) (internal note 5703)
(Insurance plan AWFH, BN1/1-U(A), BN1/2-U(A), BN3/1-U(A), BN3/2-U(A), BN HF-UZ(A), BZ 15-U(A) to BZ 70-U(A), Vision B-U(A), Premium Zahn-U(A)
It is agreed that there is no obligation to pay for current or recommended treatments for periodontal disease, as well as all prosthetic measures and
conditions that are medically proven to be causally linked. In the case of AWFH insurance plan, the agreement applies to the insurance plan chosen
when exercising the option.
11. Occlusal (bite) splint/teeth grinding guard (internal note 1955)
(Insurance plan BZ 15-U(A)to BZ 70-U(A), Vision B-U(A), Komfort Zahn-U(A), Kompakt Zahn-U(A), Premium Zahn-U(A), VZ-Zahn-U(A))
This reference in the insurance plan with the reimbursement rates
price is
EUR 20 Komfort Zahn-U(A), Kompakt Zahn-U(A), Premium Zahn-U(A) depending on the policy benefit
BZ-U(A) 70
Vision B-U(A) 00
EUR 10 BZ-U(A), Vision B-U(A), 65, 60, 55, 50T, 50, 45, 40
VZ-Zahn-U(A) 50T, 50, 5035, 45, 4530, 40, 4025
EUR 6 BZ-U(A) 35, 30, 25
Vision B-U(A) 35, 3520, 30, 3015, 25, 2515
EUR 4 BZ-U(A) 20, 15
Vision B-U(A) 20, 2015, 15
e policy
om the lternative to the reference price: exclusion of benefits
ssing For all insurance plans: (internal note 5804)
A), if It has been agreed that no insurance plan benefits will be provided for the occlusal (bite) splint/teeth grinding guard.
(Insurance plans AWFH, VIA, VIA Med, VIA Plus) (internal note 0017)
It is agreed that if the option for the occlusal (bite) splint /teeth grinding guard is exercised, a reference price of between EUR 4.00 and 20.00 will be
charged in addition to the insurance plan contribution of the selected dental insurance coverage.
Alternatively, it can be checked upon request whether benefits for the occlusal (bite) splint/teeth grinding guard can be excluded from the insu-
y, the rance coverage.
1,050.
the time
Important – Please sign and return the entire declaration, i.e. both pages, including the completed tooth formula.
e teeth please note: Many thanks.
nlays
-U(A). Signature: Place, Date (Day/Month/Year) Signature of the applicant/policyholder
Place, Date (Day/Month/Year) Signature of the co-insured person
e plan.
n acci
ce period
tion.
ARL-U,
missing
ing
depend
ents
l scale
e sub
n B-U(A))
s of any
agree
n of
e
21013908 (01.21)You can also read
