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Declaration of Membership

I would like to become a member of the AOK Hessen from

Personal information

male female
Title Name/Maiden name First name

Marital status Nationality Date of birth Place of birth

Postcode Town Street, House number

Insured number Telephone number* Mobile number*

Pension insurance number E-mail*

Information regarding current employment/training

My employment My training My studies

since/started on as will probably end on

Registration number Employer/University/Polytechnic

Postcode Town Street, House number

Unemployed** since/from Master-/customer number at the employment agency/ARGE

Voluntarily insure** since/from as

Pensioner** drawing pension since/from type of pension/pension insurance institute

** The respective proof of contributions or income are enclosed will be submitted

Information regarding insurance history

own family no statutory
membership insurance health
from to at health insurance institute

own family no statutory

membership insurance health
from to at health insurance institute

My membership with is / will be terminated on

Proof of termination is enclosed will be submitted

Are there any family members? yes no

Is family insurance required for the existing family members? yes no

My passport photograph for the new eGK I have enclosed I will submit with the picture sheet AOK already has photo

Data protection information: In order to process your insurance matters, personal data is required which the relevant AOK will save and use within the scope
of its duties ( 206, 284 SGB V). Missing, incorrect, incomplete or late information could have negative consequences ( 206 par. 2 and 307 SGB V). The
information indicated with an * is voluntary.

Consent for the AOK to use information: I consent to the relevant AOK obtaining, saving, processing and using the specified data in order to be able
to inform and advise me regarding AOK benefits and new developments, as well as optional tariffs and private supplementary auxiliary insurance from con-
tractual partners of the AOK this also applies to e-mail, telephone or SMS. I may revoke this consent at any time.

Date/signature of the customer Date/signature of the customer consultant Orga Nr.

wdv OHG, Date: January 2014, order no. o 031/432.