Create Insurance Request

Health insurance request for students in need of Mandatory health insurance for study in Germany for durations or one year or more. Please fill out all the fields accurately. Fields marked with * are mandatory.

IR:

Personal Information

First Name: *

Last Name: *

Gender: *

Male

Female

Date of Birth: *

Contact Information

Address:

Address (cont):

City:

State:

Postal Code:

Home Country: *

Your home country is a member of the European Economic Area. You don't need an additional statutory health insurance in Germany.

Email: *

Phone:

Your comments:

What code is in the image?: *

Enter the characters shown in the image.