Non-contributory Dependants Co‑insurance
Download
Preview
/
Please choose one of the following options for returning the form
E-mail
Mail
Fax
Tk Member Information
Start date of non-contributory dependants co‑insurance cover for my spouse/life partner
*
(Please indicate a date. If you do not specify a date or indicate *as of now* this information is not legally valid.)
Start date of non-contributory dependants co‑insurance for my child/children
Reason for applying for non‑contributory dependants co‑insurance
Commencement of my own membership
Marriage
Birth of my child
Termination of previous membership of my dependant
Other
Marital status
Married
Separated
Widowed
Single
Divorced
Registered Partnership
*
Previous health insurance
Not covered by statutory health insurance
Membership
Non-contributory dependants co-insurance
Spouse or Life Partner
*
* pursuant to the Lebenspartnerschaftsgesetz [German Life Partnership Law] (LPartG)
We need the following details, even if you do not wish to have your spouse/life partner
*
co‑insured with us.
(Please enclose marriage certificate if different from member's last name.)
Upload
marriage certificate.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
(If applicable)
Date of birth:
Please give us the following details if your spouse/life partner
*
does not have a German Pension Insurance Number yet.
Different address, (if applicable)
Previous health insurance of spouse/life partner
*
Not covered by statutory health insurance
Membership
Non-contributory dependants co-insurance
Non-contributory dependants co-insurance of membership of:
My spouse/life partner
*
has a personal income
No
Yes
If so, please answer the following questions for your spouse/life partner
*
Date paid employment (including mini-job) started
Average monthly gross income from marginal employment
Date self-employment started
Average monthly profit
Average working hours per week
Self-employed childminder
No
Yes
Date unemployment benefit II started
Pensions and related benefits/company pensions, foreign, national or other pensions monthly amount payable
Other average monthly income
Type of income (e.g. income from lease, interest)
(Please send us a complete copy of your last income tax assessment.)
Upload
income tax assessment.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
Kids
First Child
Second Child
(Please enclose birth certificate in case of different last names.)
Upload
birth certificate.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
Male
Female
(If date of birth, expected format is dd/mm/yyyy)
Different address
Relationship
Birth child
Foster child
Stepchild
Grandchild
My spouse/life partner is child's birth parent
Yes
No
Please give the following details if you do not have a Pension Insurance Number yet:
Previous Insurance
Not covered by statutory health insurance
Membership
Non-contributory dependants co-insurance
Period of cover
From
To
Average monthly gross income
Average monthly gross income from mini-job
Monthly profit from self-employment work
Self-employment as childminder
No
Yes
Pension and related benefits/company pensions, foreign, national, or other pensions; monthly amount payable
Other average monthly income
Entitlement to Unemployment Benefit II
No
Yes
School attendance
(Please enclose certificate of school attendance for children 23 and over.)
Upload
school attendance certificate.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
From
To
(Optional information)
Higher education
(Please enclose current enrolment receipt for children 23 and over.)
Upload
enrolment receipt.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
From
To
(Optional information)
Basic military service or alternative community service
(Please enclose a certificate of service.)
Upload
service certificate.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
From
To
(Please enclose birth certificate in case of different last names.)
Upload
birth certificate.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
Male
Female
(If date of birth, expected format is dd/mm/yyyy)
Different address
Relationship
Birth child
Foster child
Stepchild
Grandchild
My spouse/life partner is child's birth parent
Yes
No
Please give the following details if you do not have a Pension Insurance Number yet:
Previous Insurance
Not covered by statutory health insurance
Membership
Non-contributory dependants co-insurance
Period of cover
From
To
Average monthly gross income
Average monthly gross income from mini-job
Monthly profit from self-employment work
Self-employment as childminder
No
Yes
Pension and related benefits/company pensions, foreign, national, or other pensions; monthly amount payable
Other average monthly income
Entitlement to Unemployment Benefit II
No
Yes
School attendance
(Please enclose certificate of school attendance for children 23 and over.)
Upload
school attendance certificate.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
From
To
(Optional information)
Higher education
(Please enclose current enrolment receipt for children 23 and over.)
Upload
enrolment receipt.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
From
To
(Optional information)
Basic military service or alternative community service
(Please enclose a certificate of service.)
Upload
service certificate.
(Max filesize: 1 MB, Accepted Formats: pdf, jpg, png)
or
later, send to:
publicinsurance@pegaone.com
From
To
Sign
Clear
(Relax it doesn't have to be perfect)
I hereby declare that my dependants have given their consent to the processing of the required data.
Sign
Clear
(Relax it doesn't have to be perfect)
Signature of spouse if applicable.
In case you are separated, you have to sign only.
We need your personal data ("social data") to correctly perform our tasks for you. Based on the Sozialgesetzbuch (SGB V) [Social Security Code book V], we have legal responsibility to comprehensively protect your personal data.