Membership Application for People in Work

I'd like to become a member as of My gross monthly income

Day Month Year
does not exceed 450 Euros (mini-job)
Personal Information Mr Ms exceeds 4.800,00 Euros
Last Name Do you get one-off payments such as Christmas bonus or holiday
bonus? If so, please simply add one twelfth of the one-off payments to
First Name your monthly gross income.

Street, No. I had myself exempted from compulsory health insurance cover.

I had myself exempted from compulsory pension insurance cover.

Postcode and town/city
Please send us copies of your confirmations of exemption.
Date of Birth
Day Month Year Retirement Benefits
Health Insurance Number
I receive or have applied for a state pension.
You will find this on your health insurance card.
I get a pension and related benefits (e. g. company pension,
Please give your German Pension Insurance Number: pension).

Pension Ins. No. Family details

Please give the following details if you don't have a Pension Ins. No. yet: I would like to have my dependants (spouse/life partner pursuant to
the Lebenspartnerschaftsgesetz [German Civil Partnership Act])
Last name at birth covered by non-contributory dependants' insurance.

Place and country of birth The application for non-contributory dependants' insurance

Nationality is enclosed will be handed in later

Please send me an application form.

Details of previous insurance
I was last insured with Details for TK long-term care insurance
Health insurance fund I am exempt from social long-term care insurance.
Please send us a copy of your confirmation of exemption.
Location
I am mother/father of one child/several children.
from to We need this information to correctly calculate your contributions to
long-term care insurance. Please submit the relevant proof, e. g.
a copy of birth certificate.
compulsory insurance voluntary insurance
Recruit new members and win
private insurance dependants' insurance
I was recruited by

Last Name
The cancellation confirmation

is enclosed will be handed in later Address

Details for insurance cover with TK Queries and signature

I am employed/I work as The following details help us in case of queries

Phone number*
This is my first employment in Germany.
E-mail*
Employer

Street, No.

Postcode and town/city

I am in paid employment as of
X
Date Signature

I am self-employed. We need your personal data ("social data") to correctly perform our
tasks for you. This is based on Section 284 Sozialgesetzbuch V (SGB V)
[Social Security Code] and Section 94 Sozialgesetzbuch XI (SGB XI)
I am a partner in and/or manager of a GmbH [private limited
[Social Security Code].
company].

* optional information
3058339106
Techniker Krankenkasse
20901 Hamburg
 Your photograph for the electronic health card

Notes on the photo

In order that we can issue you with an electronic health card, we require a
passport photograph of you (insured parties under the age of 15 are exempted
from this requirement).
Please stick
your photo We ideally need an up-to-date photograph equivalent to a passport photograph. It
on here. does not need to be biometric, but it must have all of the following characteristics:

approx. 45 x 35 mm in size
colour or black and white
neutral background as far as possible
clearly recognisable face, photographed from the front
Please do not use copies or photos you have printed yourself.
These may not be accepted for processing for quality reasons.

We are unable to accept email submissions.

Personal Information

Ms Mr

Last Name

First Name

Date of Birth (DD MM YYYY)

Postcode Town/City

Country if not Germany

German Health Insurance Number German Pension Insurance Number

800433 04/2017

Phone Number, optional information

E-mail, optional information

I hereby certify that this photograph is a true likeness of me.

Day Month Year Signature

3846998183
Techniker Krankenkasse
20901 Hamburg