Simply the Best for You. Join Now and Enjoy the Benefits - Form Booklet 3.21
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Simply the Best for You. Join Now and Enjoy the Benefits. Form Booklet 3.21
Welcome! Daimler BKK is your competent partner when it comes to your health. Your family will also be optimally insured with us. You can look forward to our premium service, exclusive services, and extra services. Note on text For the reader’s convenience, the text frequently refers to male pronouns only. Naturally, this text is inclusive of all genders.
Freedom of Choice is Awesome!
Changing to Daimler BKK couldn’t be easier.
99 % Simply inform us that you want to change to Daimler BKK – and
of our members we will do the rest, including dealing with the paperwork with your
are satisfied with
Daimler BKK
employer and your current health insurance fund. It’s quick and
easy to become a member of Daimler BKK online.
Follow this to get to the online application:
We Have Much to Offer –
In Person ...
We offer you fair consultation – just as we would our
best friend. As trained social insurance experts, we know
our stuff. You can trust our experience and expertise.
By colleagues for colleagues
At Daimler BKK, you will be looked after by colleagues. We will provide you with a customized
and personal consultation.
We know our way around the Daimler companies, as we are present on-site and are part
of the enterprise. You will receive information and services from us that are customized for your
unique situation.
The focus of Daimler BKK is always on the person. We look after the wishes and concerns of
KUBUS is a national representative our insured members as if they were our own. Our customers value this personal touch:
survey. When it comes to assisting 99 % of our members are satisfied with us and recommend us to others.
insurance holders, we outperformed the
other health insurers: 1st place! Close at hand
We could not be any closer. Our customer centers are located at all the major Daimler locations.
Upon request, we also come to you wherever you are – at your workplace, at home, or in
the hospital.
Premium service
Ensuring you have the best possible care is what we are passionate about. Your health is in
good hands at Daimler BKK.
... And Digitally
”Meine Daimler BKK“ (My Daimler BKK) stands for the smart
service of Daimler BKK. Regardless of whether via our website or
via the Daimler BKK app – with ”Meine Daimler BKK“, you will
be able to do many things yourself in next to no time. Whenever
and wherever you want.
Our tip
If you register now for ”Meine Daimler BKK“, you will have direct access to the many
practical services.
The advantages
• Digital Mailbox
• Upload doctor’s notes, bills, and other documents
• Create a member certificate and health insurance document for abroad on your own
• Enter a change of address yourself
• Special digital health care offers: Video consultation with a doctor, Tinnitracks app in the case
of tinnitus, the mindfulness app 7Mind, BabyCare app for preventing of premature deliveries
www.daimler-bkk.com daimler-bkk.com/service-kontakt/ mediencenter/daimler-bkk-app-neu/
Exclusive for You: Our Extra Services
NEW!
Extra services for your health
Activity weeks and Well-Aktiv programs
Health & lifestyle programs for preventative health care in top
health resorts! We pay up to E160 toward your stay.
7Mind mindfulness app
Insured members of Daimler BKK can use the premium version of
this app for twelve months free of charge.
100 PRO AKTIV bonus program
We will reward you and your family if you complete various health-
enhancing measures and activities within a calendar year. You will
receive E10 for adults and E5 for children per completed measure.
Daimler BKK RückenPlus program 100 PRO AKTIV is our rewards program for the health-conscious:
This program is aimed at helping those with back, shoulder, hip, Children, teenagers, and adults who play sports, go to check-ups or
and knee problems. All you have to do is get a certificate from the health-care classes, will receive E10 (E5 for children and teenagers) for
company doctor confirming that you have a medical need. every completed measure.
Family Doctor+ trusting care
The special program for care by your family doctor. Your family
doctor will receive more money and will have more time for you
thanks to the simple processes involved. Extra services for your health care
Homeopathic remedies and naturopathic treatment
We take over costs amounting to E225. We will reimburse up to a Check-ups for those under 35
total of E100 per year for many non-prescription drugs used in We reimburse costs of up to E30 every two years.
homeopathy, phytotherapy, and anthroposophy that are available Skin cancer screening and reflected light microscopy
only from pharmacies, provided they were prescribed by a doctor We will pay up to E25 toward these tests once a year.
on a private prescription. Cancer prevention for men under 45
Personal nutrition counseling We contribute up to E15 per year.
We will support you with individual nutrition counseling if you PSA test
require a special diet due to a medical condition. We reimburse up to E20 per year to policyholders aged 20
Osteopathy and above.
We will cover 80 percent of the costs for up to six quality-assured
osteopathy sessions (maximum of E60 per treatment) per calendar
year, i.e. up to E360. Our extra services
Quality-assured health-care courses
Keep yourself fit and we’ll pay 90 percent of the course fees, up to Daimler BKK app
a maximum of E150 per course. The digital mailbox, self-services, become a member online,
Vaccinations digital care offers, and much more.
We’ll cover the cost of vaccinations required by law as well as any Video consultation
vaccinations recommended by a doctor. This medical consultation can be used via your computer or via the
Selective tariff, premium reimbursement (premium payment) Daimler BKK app – both at home and abroad!
You will be reimbursed up to one month’s premium (maximum of Digital Health Navigator
E416.03 retroactive for 2021) if you do not make any claims outside Our Digital Health Navigator will help you to assess health complaints
of check-ups and health-enhancing services. and to locally and digitally find the appropriate medical offers that
match the particular illness.
From colleagues for colleagues
Fair and competent consultation by colleagues.
Medical advice around the clock
Call our 24-hour telephone hot line INFOMED for independent advice
on all medical matters.
Podcasts and videos
Based on the theme of ”Do something for yourself“, we provide
entertaining tips on the topics exercise, relaxation, and nutrition.
Supplementary insurance
Take advantage of the enticing options offered by Daimler Vorsorge
und Versicherungsdienst GmbH.
Only the valid laws and our statutes are legally binding.
NEW!
Our extras for your pregnancy
Fertility treatment
In addition to the legally required cost contribution, we cover
additional costs arising from the treatment plan so long as both
partners are insured with us.
Medications for pregnant women
We cover costs for non-prescription proprietary medicines
containing the active ingredients iron, magnesium and/or folic acid
and available only from pharmacies if prescribed by a doctor.
Prenatal classes for partners
We will reimburse up to E50 per year for the attendance of your
partner if he/she is insured with us. The baby bonus is our reward for health-conscious parents.
Ultrasound examination in early pregnancy Moms and dads who also insure their baby with us during the first year of
We reimburse the costs of one ultrasound scan between the fourth its life can look forward to E200. The requirement here is that the moms
and ninth week of the pregnancy up to a maximum of E35. have taken advantage of the recommended preventive medical checkups
NT (nuchal) scan during pregnancy and that the baby has undergone neonatal examinations
We reimburse the costs of one NT scan per pregnancy, including U1 and U2.
laboratory services, up to a maximum of E180.
Toxoplasmosis test
We reimburse the cost for a toxoplasmosis test during the early
stages of pregnancy. If there is no sign of immune protection, we
will also carry the cost of another two tests at up to E30 per test. Being insured with Daimler BKK is worth it.
Midwife standby service In the case of a four-person family, you can
For each pregnancy, we grant a subsidy of up to E250.
easily end up with a cost benefit of over
E1,000 in the year via the use of the extra
Our extras for your family
services.
Baby bonus
Parents will receive up to E200, if they insure their newborn
You can calculate the individual benefits for
with us. The bonus applies for children born on January 1, 2021, you online directly with our ”Vorteilsrechner“
or later and with proof that the mother underwent all preventive
medical checkups during the pregnancy and that the baby has
cost benefit calculator:
undergone neonatal examinations U1 and U2.
Home assistance
You can apply for help with the cost of home assistance if you are
unable to run your household due to a serious illness. Our benefits www.daimler-bkk.com/mitglied-werden/
exceed the legal requirements. gute-gruende/vorteilsrechner/
Vision exams for the little ones
The amblyopia exam is performed twice – once between the age of
5 and 14 months and again between 20 and 50 months. We cover
up to E20 for each screening.
Preventive medical checkups U10, U11, and J2
We offer a E50 subsidy for each of these examinations.
Tooth sealant
For children and youth between the ages of 6 and 17, we subsidize
the cost of sealant for baby molars and the remaining (small) molars
4 and 5 for a maximum amount of E7.50 per tooth.
Convinced? Then you are just a few clicks away from becoming a member! It’s quick and easy to become a member online. Follow this to get to the online application: Or complete the application form and send it to: Daimler BKK, 28178 Bremen, Germany. We will take care of the rest.
Membership application Aufnahmeantrag
Personal details Persönliche Angaben
Gender Geschlecht
Health insurance number (found on your health card/ Pension insurance number (1) female male other undefined
Gesundheitskarte) Versichertennummer Rentenversicherungsnummer weiblich/männlich/divers/unbestimmt
(Diese finden Sie auf Ihrer Gesundheitskarte)
Last name Nachname First name Vorname
Date of birth (DD/MM/YYYY) Geburtsdatum Place of birth Geburtsort Nationality Staatsangehörigkeit
Street house number Straße Hausnummer Postcode town/city PLZ Ort
Telephone/mobile phone number* Telefon-/Handy-Nr.* Email address* E-Mail-Adresse* *This information is optional *Die Angaben sind freiwillig
I would like to register with the customer centre at:
Ich möchte vom Kundencenter in ... betreut werden
Insurance details Angaben zum Versicherungsverhältnis
My membership with the Daimler BKK is to begin due to a: Meine Mitgliedschaft in der Daimler BKK soll beginnen wegen:
Change of health insurance fund on: Change of employer on: (2)
Tag Monat Jahr
(cancellation notice process) DD/MM/YYYY
(immediate right of choice) DD/MM/YYYY Tag Monat Jahr
Krankenkassenwechsel zum: (Kündigungsverfahren) Arbeitgeberwechsel zum: (Sofortwahlrecht)
I am an employee Ich bin Arbeitnehmer*in I am a trainee (3) Ich bin Auszubildende*r
at Daimler AG bei der Daimler AG at Mercedes-Benz AG bei der Mercedes-Benz AG at Daimler Truck AG bei der Daimler Truck AG
at Daimler Mobility AG bei der Daimler Mobility AG Plant/branch/location: Werk/Niederlassung/Ort:
at another company: bei einem anderen Arbeitgeber:
Name of employer Name des Arbeitgebers Street house no., postcode town/city Str. Nr., PLZ Ort Telephone number Telefonnummer
I am an intern/a diploma student (4) Ich bin Praktikant*in/Diplomand*in I am completing voluntary social service Ich absolviere ein Freiwilliges Soziales Jahr (FSJ)
I am self-employed as (5): Ich bin selbstständig als: (5)
I am on parental leave (6) Ich bin in Elternzeit I am in full-time education (7) Ich bin Student*in/Schüler*in I am unemployed (8) Ich bin arbeitslos
I am retired (9) Ich bin Rentner*in I am a civil servant (10) Ich bin Beamter/Beamtin
I am the spouse/child of BKK member: Ich bin Ehepartner*in/Kind des BKK-Mitglieds:
Name of the spouse or parent who is already insured with Daimler BKK Date of birth (DD/MM/YYYY)
Name der Ehepartner*in/des Ehepartners oder Elternteils, die/der bei der Daimler BKK bereits versichert ist Geburtsdatum (Tag/Monat/Jahr)
I was ensured so far Ich war bislang versichert as compulsory member als Pflichtmitglied as voluntary member (11) als freiwilliges Mitglied
privately insured privat versichert included in family insurance at: familienversichert bei der:
Name of the health insurance fund Name der Krankenkasse Address of the health insurance fund Anschrift der Krankenkasse
This will be my first job in Germany Ich nehme erstmals eine Beschäftigung in Deutschland auf
I have just started working and do not yet have a social security ID Ich bin erstmals berufstätig und verfüge noch nicht über einen Sozialversicherungsausweis
I have children (including fostered or adopted children – attach any documentary evidence) (12) Ich habe Kinder (auch Pflege- oder Adoptivkinder – ggf. Nachweis beifügen)
I have dependents (spouse/children) who need to be covered at no additional charge (we will send you another form to complete) (13) Ich habe Angehörige (Ehepartner*in/
Kinder), die beitragsfrei mitversichert werden sollen (Sie erhalten von uns einen weiteren Fragebogen)
I would like to receive the monthly newsletter (please enter your email address above) Ich möchte den monatlichen Newsletter erhalten (Bitte oben Ihre E-Mail-Adresse eintragen)
So that your membership with the Daimler BKK can begin, we will get in contact with your previous health insurance fund via the electronic notification procedure.
*B001*
Damit die Mitgliedschaft bei der Daimler BKK beginnen kann, treten wir mit Ihrer bisherigen Krankenkasse über das elektronische Meldeverfahren in Verbindung.
Date (DD/MM/YYYY) Datum Signature Unterschrift
www.daimler-bkk.com
Data protection notice: We need your personal data (social data) to do our job properly for you. According to § 284 of the Social Security Code (SGB) V in conjunction with § 60 SGB I we are entitled to
collect the data and you are obliged to cooperate. The entry of telephone number and e-mail address is voluntary. Your information will be treated confidentially and subject to data protection. Further
information about the processing of your personal data by us and your rights under the EU General Data Protection Regulation can be found on our homepage www.daimler-bkk.com, webcode 139.
Datenschutzhinweis: Ihre persönlichen Daten (Sozialdaten) benötigen wir, um unsere Aufgaben für Sie ordnungsgemäß erledigen zu können. Nach § 284 Sozialgesetzbuch (SGB) V in Verbindung mit § 60 SGB I
sind wir berechtigt, die Daten zu erheben, und Sie zur Mitwirkung verpflichtet. Die Nennung von Telefonnummer und E-Mail-Adresse ist freiwillig. Ihre Angaben werden vertraulich behandelt und unterliegen dem
3.21
Datenschutz. Weitere Informationen über die Verarbeitung Ihrer personen-bezogenen Daten durch uns und Ihre Rechte nach der EU-Datenschutz-Grundverordnung finden Sie auf unserer Homepage
www.daimler-bkk.com, Webcode 139.Important information about your application
Please read the accompanying notes before filling out the
application in order to prevent errors and delay to your membership
certificate.
(1) Pension insurance number (Rentenversicherungsnummer) (10) I am a civil servant
Your pension insurance number can be found on your social security Please enclose your most recent payslip and proof of your
ID card. If you do not have this card available, please confirm your entitlement to aid (if available).
birth name, place of birth and nationality.
(11) During the last 18 months I was a voluntary member
(2) Change of employer (without employment)
If you change employer, you can directly become a Daimler BKK Please enclose proof of your income and, if your spouse/life partner
member without first having to give notice to your previous health is not covered by statutory health insurance, please also enclose
insurance fund. We will take over the electronic notification proof of his/her income.
procedure for you.
(12) Evidence of children
(3) Employer information To ensure your long-term care insurance premium is correct, we
We require full details of your employer so that we can send them require proof of your parental status (e.g. birth certificate).
the membership certificate. This ensures that your health insurance
cover switches over on time. (13) Family insurance
If your dependents (e.g. spouse/life partner and children) are
(4) I am an intern/a diploma student currently insured on your policy, we will check your eligibility for
Please enclose your intern/diploma student contract. family insurance with Daimler BKK. To enable us to do this, please
complete the enclosed family insurance application form.
(5) I am self-employed
Please enclose your most recent available tax assessment notice
and your business registration notice (if available). Once we have received all the necessary documents, we will
send you your personal health card (Gesundheitskarte) and
(6) I am on parental leave your membership certificate without delay. If we do not have
Please enclose confirmation of your parental allowance. a photograph of you on file, you will receive a separate letter
requesting this.
(7) I am in full-time education
Please enclose your university or school enrollment certificate.
(8) I am unemployed
Please enclose confirmation from the Federal Employment Agency/
Jobcenter (e.g. certificate of benefits granted/Bewilligungs-
bescheid).
(9) I am retired
Please enclose your pension approval certificate and, if applicable,
your company pension certificate.
Do you require assistance with completing
the forms or do you have other questions?
Then please call us at:
+49 711 17 46 555
www.daimler-bkk.comInformation on Data Processing by Daimler BKK under Art. 13
and Art. 14 of the GDPR
Daimler BKK and BKK-Pflegekasse Daimler collect, process, store and use social insurance information to fulfill their statutory mandates.
Pursuant to Art. 13 and Art. 14 of the EU‘s General Data Protection Regulation (GDPR), these organizations are required to provide certain
information when collecting personal data. In compliance with those obligations, this page gives an overview of the purposes and
legal basis for processing.
Name of Data Controller and 14. Preparing, concluding agreements on 10. Advice on entitlement to care as well as
Contact Information and implementing agreements on services and aids
Daimler BKK morbidity-based compensation 11. Coordination of nursing aids, advice on
28178 Bremen structures care and performance of duties at
15. Preparing, concluding agreements on nursing care advisory centers
Represented by its Board of and quality assurance of model projects 12. Statistical purposes
Management member and integrated care 13. Support with filing claims for
Benjamin Plocher 16. Implementation of the structural risk compensation
Tel.: 07 11 17-5 95 82 compensation plan and risk pool
Fax: 04 21 3 30 72-1 88 17. Preparing and conducting structured In addition, Daimler BKK may collect, use,
benjamin.plocher@daimler-bkk.com treatment programs (disease manage- process and store your information on the
ment programs, or DMP) basis of an express declaration of consent
Contact Information for 18. Conclusion and execution of nursing given in accordance with Art. 6, para. 1a of
Data Protection Officer care pay rate, compensation, as well as the General Data Protection Regulation
Hartmut Steffens service and quality agreements (GDPR) in conjunction with Section 67b,
Tel: 04 21 4 19-46 16 19. Advice on preventive measures and para. 2 of the Book 10 of the Code of Social
Fax: 04 21 3 30 72-2 77 rehabilitation Law (SGB X).
datenschutz@daimler-bkk.com 20. Coordination of nursing aids We are permitted, in deviation from the
21. Statistical purposes purposes and legal basis stated above, to
Purposes and Legal Basis of Processing 22. Acquisition of members use your information for other purposes
Daimler BKK collects, processes, stores and 23. Implementation of the Aufwendungsaus- (change of purpose) without informing you in
uses social insurance information to fulfill gleichsgesetz (AAG – German Act on advance, provided the following conditions
their statutory mandates. The lists below Compensation of Employer Expenses are met:
provide you with an overview of the purposes for Employee Sickness Benefits) 1. The action is being taken in accordance
for which the medical insurance company with Section 82, para. 2, of SGB X
(Daimler BKK) and the nursing insurance II. BKK-Pflegekasse Daimler 2. A different legal provision allows a
company (BKK-Pflegekasse) process your 1. Support for individuals in need of care change of purpose without requiring us
information and the legal basis of such who require assistance because of the to inform you
processing. severity of their disability 3. You have given your express consent
2. Financing of services and other 4. The information has been pseudony-
I. Daimler BKK expenses by collecting premiums from mized
1. Establishment of insurance coverage employers and members
2. Issuance of health insurance cards and 3. Determining insurance coverage and Provision of Social Insurance Information
electronic health care cards membership In order for Daimler BKK to fulfill its statutory
3. Dealing with matters involving 4. Determining obligation to pay premiums duties to the fullest extent, please note that
insurance premiums and what amounts you have a duty to cooperate pursuant to
4. Evaluating and granting benefits 5. Evaluating entitlement to benefits and Sections 60 et seq. of the Book 1 of the
5. Supporting insured persons in cases of providing benefits to insured persons Social Security Code (SGB I). The law states
malpractice as well as processing of claims for that you are required to provide Daimler BKK
6. Reimbursement of expenses reimbursement and compensation with certain information about yourself that
7. Determining copayment status and 6. Consultation with the medical service is required for the performance of statutory
out-of-pocket limits 7. Settlement of invoices from service duties on your behalf. A failure to cooperate
8. Refunding of premiums providers and corresponding on your part may result in delays or denial of
9. Consultation with the medical service reimbursement the benefits requested by you.
10. Billing of service providers 8. Monitoring of cost-effectiveness, plus Voluntary information such as your telepho-
11. Cost effectiveness and quality audits of settlement and reimbursement of ne number and e-mail address are expressly
service providers nursing care provided exempt from the information you are
12. Settlement of invoices from other 9. Conclusion and execution of nursing required to provide. If you do not provide us
service providers care pay rate, compensation, as well as with that information, you will not be in
13. Filing claims for reimbursement and service and quality agreements violation of your duty to cooperate, and you
compensation from third parties will suffer no disadvantages.
>>Your social insurance information that Retention Period 2. German Federal Insurance Office
Daimler BKK is required to collect, process, Various retention periods apply to the Friedrich-Ebert-Allee 38
store and use falls under the data protection purposes of processing social insurance 53113 Bonn
provisions of SGB X, the Bundesdatenschutz- information. Those periods are governed by poststelle@bvamt.bund.de or
gesetz (BDSG – German Federal Data Section 110a of SGB IV, Section 304 of SGB poststelle@bvamt.de-mail.de
Protection Act) and, as of May 25, 2018, the V, Section 107 of SGB XI and in the General
EU‘s General Data Protection Provision Administrative Regulation on Accounting in You can find additional information about
(GDPR). Daimler BKK ensures that it the Social Insurance Industry (SRVwV). Once data protection and your rights under the EU
complies with the rules governing the the purpose of processing no longer applies, General Data Protection Regulation on our
secrecy of social insurance information in the relevant social insurance information website at www.daimler-bkk.com,
accordance with Section 35 of SGB I. data will be deleted. Webcode 139.
Automated Individual Decision-Making Rights of Data Subjects Regarding Data
Daimler BKK does not make decisions based Processing
on automated processing, including profiling, By contacting the individuals named above,
as defined by Art. 22 of the GDPR. you can assert the following rights if the
legal requirements are met:
Categories of recipients • Right to access and information about
Daimler BKK regularly transmits social the processed data (Art. 15 of the GDPR
insurance information based on the legal in conjunction with Section 83 of SGB X)
requirements of the SGB or other legal • Right to rectification of incorrect data
regulations to the following recipients: (Art. 16 of the GDPR in conjunction with
• Carriers of pension and accident Section 84 of SGB X)
insurance • Right to erasure (Art. 17 of the GDPR in
• Germany’s Federal Employment Agency conjunction with Section 84 of SGB X)
• Financial institutions as part of payment • Right to restriction of processing (Art. 18
transactions of the GDPR in conjunction with Section
• Employers and payment authorities 84 of SGB X)
• Pension administration offices • Right to data portability (Art. 20 of the
• Service providers GDPR)
• Military district administrative offices • Right to object (Art. 21 of the GDPR in
• Tax authorities conjunction with Section 84 of SGB X)
• Transmission in individual cases in • In the case of data processing based on
accordance with Sections 67d et seq. consent, you have the right to withdraw
of SGB X your consent permanently at any time
• External contract data processors in
accordance with Section 80 of SGB X Right to Lodge a Complaint with
Supervisory Authorities
If we transmit your information to one of As a data subject, you have the right to
these categories of recipients, we will inform contact the competent supervisory authori-
you of the recipient, unless one of the ties with jurisdiction over Daimler BKK:
exceptions stipulated under Section 82,
paras. 1 and 2 of SGB X or the conditions 1. Federal Commissioner for Data Protection
laid out in Art. 13, para. 4, of the GDPR and Freedom of Information
apply. Graurheindorfer Straße 153
53117 Bonn
poststelle@bfdi.bund.de or
poststelle@bfdi.de-mail.de”We feel we are in good hands here“ Follow this for the online application for family insurance at no additional charge:
Application form for family insurance
Antrag für die Familienversicherung
1. Member’s details Angaben zum Mitglied 2. Details about the additional person/people to be insured
on the member policy Angaben zur Person, die mitversichert werden soll
Last name Nachname My spouse/life partner1 needs to be
covered at no additional charge from:
Day Month Year (Tag/Monat/Jahr)
Mein/-e Ehe-/Lebenspartner*in1 soll
First name Vorname beitragsfrei mitversichert werden ab:
My child/children need/s to be
Daytime telephone number/Email (this information is optional) covered at no additional charge from:
Telefon tagsüber/E-Mail (Die Angaben sind freiwillig) Mein/-e Kind/-er soll/-en beitragsfrei Day Month Year (Tag/Monat/Jahr)
mitversichert werden ab:
As per the German Life Partnership Act (LPartG)
1
Health insurance number (found on your health card/Gesundheitskarte) Eingetragene Lebenspartnerschaft nach dem Lebenspartnerschaftsgesetz
1
Versichertennummer
(LPartG)
3. Reason for inclusion in family insurance 4. Marital status of member Familienstand
Anlass für die Aufnahme in die Familienversicherung
Single Married Separated
Start of my membership Birth of child Marriage Ledig Verheiratet Getrennt lebend
Beginn meiner Mitgliedschaft Geburt des Kindes Heirat
Divorced since Widowed
End of family member’s individual membership Geschieden seit Verwitwet
Beendigung der vorherigen eigenen Mitgliedschaft des/der Angehörigen
Registered life partnership* Eingetragene Lebenspartnerschaft*
Other:
Sonstiges
Why do we need this information for family insurance? Warum sind Ihre Angaben zur Familienversicherung wichtig?
For dependents to qualify for insurance cover at no additional cost, certain Für eine beitragsfreie Mitversicherung von Angehörigen gelten bestimmte
legal requirements must be fulfilled. This is why we need information about gesetzliche Auflagen. Deshalb benötigen wir die Angaben zu Ihrem/Ihrer Ehe-/
your spouse/life partner even if you only want to insure your children on your Lebenspartner*in auch dann, wenn Sie nur Ihre Kinder bei uns versichern wollen
policy – this ensures, among other things, that insurance is not held with more – u.a. damit ausgeschlossen ist, dass eine gleichzeitige Versicherung bei ver-
than one health insurance fund at the same time. If your spouse/life partner schiedenen Krankenkassen besteht. Ist Ihr/-e Ehe-/Lebenspartner*in mit den
is related to the child/children, but not a member of any statutory health Kindern verwandt, aber nicht Mitglied einer gesetzlichen Krankenkasse, benöti-
insurance fund, we require proof of income. In line with legal requirements gen wir Einkommensnachweise. Im Rahmen der gesetzlichen Auflagen erhalten
you will receive a questionnaire from us each subsequent year, which must be Sie künftig einmal jährlich von uns einen Fragebogen für die Weiter-führung der
completed to continue family insurance. Familienversicherung.
5. Spouse/life partner 6. Child/children
Ehe-/Lebenspartner*in Kind/-er
Even if your spouse/life
partner does not need to be I would like child/children to be covered on my insurance
covered with us, we still Ich möchte Kind/-er mitversichern
require the following information
Auch wenn Ihr/-e Ehe-/
Lebenspartner*in nicht bei
uns mitversichert werden
soll, benötigen wir folgende
Angaben
General family member details Spouse/life partner Child 1 Child 2 Child 3
Allgemeine Angaben zum Familienmitglied Kind 1 Kind 2 Kind 3
Last name Nachname
If last name differs from that of the member, please enclose birth certificate or marriage/genealogical certificate (Abstammungsurkunde) as appropriate
Bei vom Mitglied abweichendem Nachnamen bitte Geburts- bzw. Heirats-/Abstammungsurkunde beifügen
First name Vorname
Gender (female/male/other/undefined)
Geschlecht (weibl./männl./divers/unbestimmt) (f) (m) (o) (u) (f) (m) (o) (u) (f) (m) (o) (u) (f) (m) (o) (u)
Date of birth Geburtsdatum
(Tag/Monat/Jahr) Day Month Year Day Month Year Day Month Year Day Month Year
*B002*
Address if different from that of member
Street house number/postcode town/city
Ggf. abweichende Adresse
Straße Hausnummer, PLZ Ort
www.daimler-bkk.comApplication form for family insurance Antrag für die Familienversicherung 2
Last name Nachname First name Vorname Health insurance number Versichertennummer
General family member details Spouse/life partner Child 1 Child 2 Child 3
Allgemeine Angaben zum Familienmitglied Ehe-/Lebenspartner*in Kind 1 Kind 2 Kind 3
How is the child related to the member? Biological child2 Biological child2 Biological child2
Verwandtschaftsverhältnis zum Mitglied Leibliches Kind*
2
Stepchild Stepchild Stepchild
Biological child“ should also be used if the child
Stiefkind
2
is adopted Bei adoptiertem Kind auch hier ankreuzen
Grandchild Grandchild Grandchild
Enkelkind
Foster child Foster child Foster child
Pflegekind
Is the spouse/life partner the natural parent of the child? Yes Ja Yes Yes
Ist der/die Ehe-/Lebenspartner*in der leibliche Elternteil des Kindes? No nein No No
Details of the last insurance or
any existing insurance held by
the family members Spouse/life partner Child 1 Child 2 Child 3
Angaben zur bisherigen Krankenversicherung
der Familienmitglieder
Current health insurance Membership Membership Membership Membership
Art der bisherigen Krankenversicherung Mitgliedschaft
Family insurance Family insurance Family insurance Family insurance
Familienversicherung
Non-statutory Non-statutory Non-statutory Non-statutory
Nicht gesetzlich
Period of insurance cover from vonfrom
Versicherungszeitraum von
(Tag/Monat/Jahr) Day Month Year Day Month Year Day Month Year Day Month Year
to bis to
bis Day Month Year
(Tag/Monat/Jahr) Day Month Year Day Month Year Day Month Year
Held with (name and address of the
health insurance fund) Name und Adresse
der Krankenkasse
Health insurance number
(found on your health card/Gesundheitskarte)
Versichertennummer
Pension insurance number
Rentenversicherungs-Nr.
If pension insurance number not yet available, please state:
Falls noch keine Rentenversicherungsnummer vorliegt, bitte angeben:
Birth name Geburtsname
Place of birth Geburtstag
Country of birth Geburtsland
Nationality Staatsangehörigkeit
www.daimler-bkk.comApplication form for family insurance Antrag für die Familienversicherung 3
Last name Nachname First name Vorname Health insurance number Versichertennummer
Income Spouse/life partner Child 1 Child 2 Child 3
Einkünfte
The familiy member has an own income Yes Yes Yes Yes
Das Familienmitglied hat ein eigenes Einkommen Ja
If yes, please answer the following details. Details required for children aged 14 or over
Wenn ja, bitte folgende Punkte beantworten. Angaben für Kinder ab 14 Jahren erforderlich
Average monthly gross income3 E E E E
Durchschnittliches monatliches Bruttoarbeitsentgelt
Average monthly gross income from
marginal employment/mini-jobs E E E E
Durchschnittliches monatliches Bruttoarbeitsentgelt aus Minijob
Average monthly profit from
self-employed work3 E E E E
Durchschnittlicher monatlicher Gewinn aus selbstständiger Tätigkeit
Monthly income from statutory pension
and related benefits, company pension,
pension from another country,
other pensions3 E E E E
Gesetzliche Rente, Versorgungsbezüge, Betriebsrente, ausländ. Rente, sonstige Renten (monatlich)
Other regular monthly income E E E E
Sonstige regelmäßige Monatseinkommen
Type of income3
For example, income from property, leasing, investment income, or severance pay Z.B. Einkünfte aus Vermietung, Verpachtung, Kapitalvermögen oder Abfindung
3
Please attach copy of latest income tax assessment (in full) 3 Bitte vollständige Kopie Ihres aktuellen Einkommensteuerbescheids beifügen
Recipient of unemployment benefit II Yes Yes Yes Yes
Bezug von Arbeitslosengeld II
Self-employed Yes Yes Yes Yes
Selbstständige Tätigkeit liegt vor
School or higher education School Studies School Studies School Studies
For children aged 23 or over, please
enclose certificate of schooling or from von Day Month Year Day Month Year Day Month Year
studies Schul- oder Studienzeit (Tag/Monat/Jahr)
Bitte bei Kindern ab 23 Jahren
Schul- oder Studienbescheinigung Day Month Year Day Month Year Day Month Year
beifügen (Tag/Monat/Jahr)
Military, civilian or voluntary service
as proof of
Please enclose certificate
service period from von Day Month Year Day Month Year Day Month Year
Bitte Dienstzeitbescheinigung beifügen (Tag/Monat/Jahr)
to bis Day Month Year Day Month Year Day Month Year
(Tag/Monat/Jahr)
I confirm that the details provided are accurate. I will inform you immediately of any changes. This applies in particular if there is any change in the
income of my family member/s shown above (e.g. new income tax assessment for a self-employed person) or if any of the family members themselves join
a (different) health insurance fund.
Ich bestätige die Richtigkeit der Angaben. Über Änderungen werde ich Sie umgehend informieren. Das gilt insbesondere, wenn sich das Einkommen meines/meiner
o.a. Angehörigen verändert (z.B. neuer Einkommensteuerbescheid bei selbstständiger Tätigkeit) oder diese selbst Mitglied einer (anderen) Krankenkasse bzw. einer
anderen Krankenversicherung werden.
Date Datum Member’s signature Unterschrift des Mitglieds Family member’s signature (if applicable) Ggf. Unterschrift des/der
By signing this document, I confirm that I have obtained the Familienangehörigen
consent of the family member/s to supply the necessary Where family members are living separately, the signature of the
information. Mit der Unterschrift erkläre ich, die Zustimmung des/ family member/s is sufficient. Bei getrennt lebenden Familienan-
der Familienangehörigen zur Angabe der erforderlichen Daten gehörigen reicht die Unterschrift des/der Familienangehörigen aus.
erhalten zu haben.
Data protection notice: In order for us to be able to assess the family insurance, your participation according to §§ 10 Abs. 6, 289 SGB V is required. The data are to be collected for determining the insurance
relationship (§§ 10, 284 SGB V, § 7 KVLG 1989, § 25 SGB XI). The details of contact details (e-mail and telephone number) are voluntary and will only be used for queries regarding your insurance relationship.
Further information about the processing of your personal data by us and your rights under the EU General Data Protection Regulation can be found on our homepage www.daimler-bkk.com, webcode 139.
Datenschutzhinweis: Damit wir die Familienversicherung beurteilen können, ist Ihr Mitwirken nach §§ 10 Abs. 6, 289 SGB V erforderlich. Die Daten sind für die Feststellung des Versicherungsverhältnisses (§§ 10, 284
SGB V, § 7 KVLG 1989, § 25 SGB XI) zu erheben. Die Angaben zu Kontaktdaten (E-Mail und Telefonnummer) sind freiwillig und werden ausschließlich für Rückfragen zu Ihrem Versicherungsverhältnis verwendet.
Weitere Informationen über die Verarbeitung Ihrer personenbezogenen Daten durch uns und Ihre Rechte nach der EU-Datenschutz-Grundverordnung finden Sie auf unserer Homepage www.daimler-bkk.com,
Webcode 139.
www.daimler-bkk.comE20
bonus for you
Refer a Friend
Recommend us – it is worth it!
Win over others – from your own satisfaction as a Daimler BKK member
If you are happy with our service, then please pass on this to your colleagues. Your good
experiences provide the best arguments for becoming a member of Daimler BKK.
Or win over your spouse who does not work for Daimler.
You can also recommend us to your children who are already part of the family insurance and
need insurance themselves due to starting their own careers or studies.
You will receive a E20 bonus for every new member.You can also read
