Mandatory fields are marked with a *:
I would like to become a member of IKK Südwest.*
Membership start date:*
Title:* Mr Ms
First name:*
Surname:*
Date of birth:* dd/mm/yyyy
Pension insurance number:
If you do not know your pension insurance number, please provide your country/place of birth and your name at birth.
Tax ID number:
Place of birth:*
Country of birth:
Name at birth:
Nationality:*
Marital status:
Street name and number:*
Additional address information:
Postcode, town/city:*
Email:*
Telephone number:
Current pension insurance provider:*
Since:
Termination of previous health insurance: Has not yet taken place Was completed on:
Employer:*
Employer telephone number:
Occupation:
Employed since:
Previous insurance coverage: Compulsory insurance Voluntary insurance Family insurance
I have dependents who should be included in IKK Südwest’s insurance without contributions:
Yes No
If we need any further information, we will contact you directly.
I consent to IKK Südwest storing and using my data to provide me with information and advice in writing (including email) or by telephone. My data will of course be protected and treated confidentially. It will not be passed on to third parties. I may limit or cancel this declaration of consent at any time.
Declaration of consent* I agree to the declaration of consent I do not agree to the declaration of consent
Comments:
I hereby consent to the processing of my personal data.
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Date: 03/12/2024
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