First and last name

Email for inquiries

Phone

Date of Birth

Current Residence – Country

Current Address

Nationality

Additional persons to be insured Please only provide names, dates of birth, and relationship to the requesting person. Do not enter health data.

Your accommodation situation

Country of planned main residence

Additional countries planned?

Additional countries of residence

Protection needed in the USA or Canada?

Desired Insurance Start

End of stay

Planned end date

Expected end date

Is the primary residence being relocated?

Main reason for the stay Please select… Trip or visit Studies or Training Professional activity Secondment Self-Employment Emigration Family reunification Retirement Miscellaneous

Additional information on purpose of stay

University or Training Institution

Employer and job title

Sending employer and place of assignment

Type of self-employed activity

Visa or Residence Permit Requires Proof of Insurance?

Requirements for proof of insurance For example, requirements of the university or authority; do not enter identification numbers.

Is there currently health insurance?

Insurer and insurance country

Type of Existing Protection Please select… Statutory Private Travel health insurance Other Unclear

Existing Protection Ends On

Has the stay already begun?

Start of the current stay

Additional information on previous protection

Outpatient and inpatient treatment desired?

Dental services desired?

Return transport desired?

Home visits to be insured?

Desired monthly budget

Additional wishes or special requirements Please do not enter diagnoses, findings, or detailed health information. If necessary, we will clarify this via a suitable separate process.

What else should we know for the consultation?

Preferred Contact Channel Please select… Email Phone

Convenient time for a callback

Are the details complete to the best of your knowledge? This is a consultation request, not an insurance application. Insurance coverage only arises through a corresponding confirmation from the insurer.