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PRIVATE - Risk assessment accident insurance

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Schritt 1 von 7 Your Form Progress

Name (Insured Person 1) Surname of the insured / person to be insured

First name (insured person 1) First name of the insured / to be insured person

Occupation (insured person 1) Currently Practiced Profession

Date of Birth (Insured Person 1)

Gender (insured person 1)

weiblich

male

1.1. Gesundheitsfragen – nur zur Orientierung – maßgeblich sind die Antragsfragen des jeweiligen Versicherers.

Are there or were there significant health impairments in the last 5 years?

yes

Significant are especially illnesses or impairments that have led to hospital treatment or outpatient joint surgery in the last 5 years, have been regularly treated with medication in the last 12 months, have resulted in a severe disability, or represent a visual impairment of 8 or more diopters.

More detailed information on significant health impairments (if yes)

Are there any further health impairments that have not been explicitly asked about so far?

yes

Do you practice dangerous hobbies? (e.g. skydiving, rafting, bungee jumping, free climbing, gliding, martial arts)

yes

Dangerous Hobbies (if yes, which ones?)

Die nachfolgenden Berechnungen sind nur als Vorschlag zu verstehen. Je nach persönlicher Situation muss davon abgewichen werden – insbesondere wenn bereits durch andere Versicherungen eine (Teil-)Absicherung besteht.

Disability Sum (Suggestion: Annual Income × 3, minimum €100,000)

Progression

Todesfallleistung: Soll dieses Risiko über die Unfallversicherung oder eine separate Risikolebensversicherung (Ri-LV) abgedeckt werden? Vorschlag: Die Todesfallleistung sollte ca. in Höhe des 250-fachen monatlichen Kapitalbedarfs der Hinterbliebenen (zzgl. offener Kredite) abgesichert werden.

Type of coverage for death benefit

Accidental Death (Death Benefit via Accident Insurance) in €

Krankenhaustagegeld / Genesungsgeld: Soll ein Ausgleich der finanziellen Mehrbelastung aufgrund eines Krankenhausaufenthaltes über die Unfallversicherung oder über eine Krankenversicherung erfolgen? Vorschlag: Um einen Ausgleich zum verminderten Krankentagegeld zu erhalten, sollte ca. 2 % des monatlichen Nettoeinkommens abgesichert werden.

Type of coverage for hospital daily allowance / convalescence benefit

Accident Hospital Daily Allowance (Accident HDA) in € per Day

Unfallrente: Soll eine Rentenleistung über die Unfallversicherung oder über eine separate Berufsunfähigkeitsversicherung (BU) dargestellt werden? Vorschlag: Wenn eine Unfallrente gewünscht wird, sollte diese ca. die Höhe des monatlichen Nettoeinkommens erreichen.

Type of coverage for accident pension

Accident Pension in € per month

Weitere Einschlüsse: Wünschen Sie den Einschluss / die Erweiterung folgender Leistungen?

Additional benefit components

Assistance Services

Increased physical exertion

Own movement

Mental and Consciousness Disorder

Insect Bites

Vaccination Injuries (open list)

Performance improvements / update guarantee

Please select the desired benefit components.

Immediate benefit up to €

Transitional benefit up to €

Salvage costs up to €

Cosmetic operations up to €

Spa Treatment Allowance up to €

Participation share – regulation

Participation share in % (individual)

Other desired services / notes Other service requests or remarks regarding the included topics.

Is there or was there a previous insurance? (Person 1)

yes

Previous insurance – Company (Person 1)

Previous Insurance – Policy Number (Policy No.) (Person 1)

Previous insurance – Expiry (Person 1) Expiration Date of Previous Insurance

Termination of Previous Insurance by (Person 1)

Policyholder

Insurer

Reason for Termination (if terminated by insurer) (Person 1)

Previous insurance – Disability base sum in € (Person 1)

Previous insurance – Progression in % (Person 1)

Previous insurance – Death benefit in € (Person 1)

Previous insurance – Hospital daily allowance (KHTG) in € per day (Person 1)

Previous insurance – Convalescence allowance in € per day (Person 1)

Previous insurance – Accident pension in € per month (Person 1)

Previous insurance – Immediate benefit in € (Person 1)

Previous Insurance – Transition Benefit in € (Person 1)

Previous insurance – Assistance services included? (Person 1)

yes

Previous damages in the last 5 years (Person 1)

none

Previous damages present

Number, type and amount of prior damages in the last 5 years (Person 1)

Is additional insurance coverage desired? (Person 1)

yes

Desired additional insurance coverage (Person 1)

Disability insurance

Supplementary health insurance

Dread disease

Additional information on desired insurance coverage (Person 1)

Name (Insured Person 2) Surname of the insured / person to be insured

First name (insured person 2) First name of the insured / to be insured person

Occupation (insured person 2) Currently Practiced Profession

Date of Birth (Insured Person 2)

Gender (insured person 2)

weiblich

male

2.1. Gesundheitsfragen – nur zur Orientierung – maßgeblich sind die Antragsfragen des jeweiligen Versicherers.

Are there or were there significant health impairments in the last 5 years? (Person 2)

yes

More detailed information on significant health impairments (if yes, person 2)

Are there any further health impairments that have not been explicitly asked about so far? (Person 2)

yes

Do you practice dangerous hobbies? (e.g. skydiving, rafting, bungee jumping, free climbing, gliding, martial arts) (Person 2)

yes

Dangerous Hobbies (if yes, which ones?) (Person 2)

Disability Sum (Suggestion: Annual Income × 3, minimum €100,000) (Person 2)

Progression (Person 2)

Type of coverage for death benefit (Person 2)

Accidental Death (Death Benefit via Accident Insurance) in € (Person 2)

Type of coverage for hospital daily allowance / convalescence benefit (Person 2)

Accident Hospital Daily Allowance (Accident KHTG) in € per day (Person 2)

Type of coverage for accident pension (Person 2)

Accident Pension in € per month (Person 2)

Sofortleistung, Übergangsleistung, Assistance-Leistungen – wünschen Sie den Einschluss dieser Leistungen?

Inclusion of Immediate Benefit / Transitional Benefit / Assistance Services (Person 2)

yes

Immediate benefit in € (Person 2)

Transitional benefit in € (Person 2)

Assistance Services Included? (Person 2)

yes

Weitere Einschlüsse – sind nachfolgend aufgeführte Positionen mit den angegebenen Summen ausreichend? • Bergungskosten: 5.000 € • kosmetische Operationen: 5.000 € • Kurkostenbeihilfe: 1.000 €

Are the stated standard sums sufficient? (Recovery costs, cosmetic surgery, convalescence allowance) (Person 2)

yes

Desired minimum amount (if standard amounts are not sufficient, person 2)

Is there or was there a previous insurance? (Person 2)

yes

Previous insurance – Company (Person 2)

Previous Insurance – Policy Number (Policy No.) (Person 2)

Previous insurance – Expiry (Person 2) Expiration Date of Previous Insurance

Termination of Previous Insurance by (Person 2)

Policyholder

Insurer

Reason for termination (if terminated by insurer) (Person 2)

Previous insurance – Disability base sum in € (Person 2)

Previous insurance – Progression in % (Person 2)

Previous insurance – Death benefit in € (Person 2)

Previous insurance – Hospital daily allowance (KHTG) in € per day (Person 2)

Previous insurance – Convalescence allowance in € per day (Person 2)

Previous insurance – Accident pension in € per month (Person 2)

Previous insurance – Immediate benefit in € (Person 2)

Previous Insurance – Transition Benefit in € (Person 2)

Previous insurance – Assistance services included? (Person 2)

yes

Previous damages in the last 5 years (Person 2)

none

Previous damages present

Number, type and amount of prior damages in the last 5 years (Person 2)

Is additional insurance coverage desired? (Person 2)

yes

Desired additional insurance coverage (Person 2)

Disability insurance

Supplementary health insurance

Dread disease

Additional information on desired insurance coverage (Person 2)

Requested payment method

Requested payment frequency 1/1 = jährlich, 1/2 = halbjährlich, 1/4 = vierteljährlich, 1/12 = monatlich

Other notes, remarks

Einverständniserklärung zur Datenweitergabe und Belehrung: Bei den Fragen handelt es sich um Fragen über gefahrerhebliche Umstände. Unvollständige und unrichtige Angaben zu den gefahrerheblichen Umständen berechtigen den Versicherer, im Falle der vorsätzlichen oder grob fahrlässigen Verletzung der Anzeigepflicht, vom Versicherungsvertrag zurückzutreten. Wird die Anzeigepflicht vorsätzlich oder grob fahrlässig verletzt, hat der Versicherer das Recht, den Vertrag innerhalb eines Monats ab Kenntnis von der Anzeigepflichtverletzung unter Einhaltung einer Frist von einem Monat zu kündigen. Diese Daten werden ggf. zur weiteren Verarbeitung (z.B. Angebotserstellung, Schadenbearbeitung etc.), wie in der "Einwilligungserklärung zur Datenverarbeitung" beschrieben, an Versicherer und Dienstleister weitergeleitet.

Date (Signing)

Customer's signature

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