Your data sheet – kaiserlichberaten

1. About you

Title (Mr/Ms) Academic title First name Last name Date of birth Place of birth Nationality Marital status

Address and contact

Street and house number Postcode City Email Phone / mobile Living situation Driving licence since

2. Family

Do you have a partner?

YesNo

Children

3. Work and income

Employment status Occupation / job Employer / company Working there since Gross income per year (€) Net income per month (€) How much of your working time do you spend at a desk?

Health insurance

You are insured … With which insurer / health fund?

4. Bank details

I need your bank details so that insurance premiums can be collected. A direct debit only happens with a separate SEPA mandate that you sign for each contract.

Account holder Bank IBAN

5. Health

Is there anything about your health that we should talk about?

For example ongoing treatment, a pre-existing condition or regular medication. This only matters for some insurances, such as disability, accident or life cover. You don’t need to give any details here – if it matters, I will ask.

Yes, please ask meNo

6. Finish

Is there anything else you’d like to tell me? (please no health details)

Everything in one place.

1. About you

Address and contact

2. Family

3. Work and income

Health insurance

4. Bank details

5. Health

6. Finish

Thank you, your details have arrived.

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