Docstoc

DAAD Deutscher Akademischer Austausch Dienst German Academic

Document Sample
DAAD Deutscher Akademischer Austausch Dienst German Academic Powered By Docstoc
					                             DAAD                         Deutscher Akademischer Austausch Dienst
                                                          German Academic Exchange Service


                                                          Insurance office - 111



Application form for a special combined Sickness, Personal Accident, and Private Liabi-
lity by the DAAD Group Insurance Scheme
For foreign Practical Trainees in Germany
Tariff: 720

Monthly premium: EUR 23,50
The insurance has to be concluded upon the day of arrival. Insurance can be started every day of the month and
will be valid for 30 respectively 31 days (Example: start 14th January, end 13th of the respective month for which
premiums were paid). We cannot accept payments for daily or weekly insurance periods. If possible the total
amount of insurance should be paid for the whole period of your stay. We would kindly ask to pay in quarterly
installments if you are staying für a prolonged period. Please indicate always your insurance number when
transfering money to our bank account (to be started with the 2nd money transfer for your insurance).

Your personal data will be stored in our data processing and the one of our insurance partners




Insured Person:
If you are already insured with us please indicate your
respective insurance number:

Name:
First name:
Date of birth:
Sex:
Home country:
Begin and end of stay:
Sponsored or supported by:
Begin of insurance:
Probable insurance period:




                             Kennedyallee 50, D-53175 Bonn, Tel. (0228) 882-0, Fax: (0228) 882-444, http://www.daad.de
DAAD                   page 2




The premium amount of EUR ______________ will be paid to: DAAD-Versicherungsstelle, Ac-
count-Nr. 02 085 124 00, Dresdner Bank Köln, BLZ 370 800 40
The insured persons will receive the respective insurance-policy as soon as the premium
has been credited to our bank account (processing period 1 week).


                                                                          Yes / No
Do you consider to be healthy?
Are you currently receiving medical treatment or is such treatment
planned
I have taken notice of the conditions of the DAAD Group Insurance
Scheme


The insurance policy should be sent to: (address)




For technical reasons applications can only be received by mail or by fax for the time bee-
ing.
German Academic Exchange Service (DAAD)
Insurance Office
Kennedyallee 50
53175 Bonn
Fax: 0228 / 882 620

				
DOCUMENT INFO