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Evaluation form
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Information for social insurance assessment
4. Yes, I am/have been registered with the Federal Employment Agency in the last 12 months as available for work and/or have received
benefitsfromtheAgencyfrom to
No,IagreetoprovidenotificationwithoutdelaywheneverIregisterasunemployed.
5. Iam/was aschoolstudentuntil Nameandlocationofschool: andintendto
attend college from
attend vocational school from
beginwork(e.g.apprenticeship,voluntarymilitaryservices/nationalvoluntaryservice)from
Iam ahousewife/husband doingvoluntarymilitaryservice/nationalvoluntaryservice inthearmedforces
acivilservant anemployee onparentalleave apensioner(e.g.retirementpension/disability)
1. Name:
Firstname:
Dateofbirth:
Pensioninsurancenumber:
Employed from to
Workingstudent Trainee(voluntary) Schoolstudent Universitystudent(undergraduate/postgraduate)
Trainee(mandatory) A-levelstudent PhDstudent Other:
Regularweeklyworkinghours(hrs): Workonwhatdays?
Monthlygrossearnings(includingregularspecialpayments)€:
Street/No.:
Postcode:
City:
E-mailaddress:
Department/tel.:
3. Yes,Iamalsoemployedorworkingonaself-employedbasis.Iwillprovidenotificationofanytermination/changeinthisworkwithoutdelay.
Nameofcompany:
Averagemonthlygrosssalary€:
Workingdays:
No,IagreetoprovidenotificationwithoutdelayassoonasIstartworkinginanycapacity.
From to
Averageweeklyworkinghours(hrs):
Employee‘s pers. no.:(tobecompletedbytheemployer)
2. Ihavebeenemployedinthelast12months: No Yes,by:
Nameofcompany:
From to
Averagemonthlygrosssalary€:
Averageweeklyworkinghours(hrs):
Workingdays:
Mandatoryinternship: Yes No
Nameofcompany:
From to
Averagemonthlygrosssalary€:
Averageweeklyworkinghours(hrs):
Workingdays:
Mandatoryinternship: Yes No
8. Iamcurrently amemberinsuredthroughmyfamilywiththefollowinghealthinsurer:
Iamcurrentlyprivatelyinsuredwith
Date Name/firstname(blockletters)Phone(mobile) Signature
By signing here, I ensure that the information in this form is correct. I agree to provide notification of any changes without delay.
9. Yes,IagreethatthedataIprovideherewillbesubmittedtoSBKinordertoassesstheirrelevanceforsocialinsurancepurposesandwillbeavailabletoSBKforthedurationofmyemploymentforverificationpurposes.IherebyagreetoallowSBKtousethedataprovidedhereforsuchpurposesandtocontactmebymailandbytelephone. Yes,IwouldliketoreceivevaluableinformationonthebenefitsandinsuranceofferingsoftheSBK.IherebyagreetoallowSBKtousethedataprovidedhereforsuchpurposesandtocontactmebymailandbytelephone.
Employee‘s pers. no.:(tobecompletedbytheemployer)
6. Iam afull-timestudent currentlyonleavedueto
anon-enrolledstudent nolongeraregisteredstudentsince
officiallybeennotifiedoftheoverallresultofthefinalexaminationofmybachelor/mastercourse(Printandcrossoutinappropriate
options)inwritingon
7. Ihavebeenregisteredsince thesummer/wintersemester
and am in the semester at
full-timestudies
part-timestudies–Standardperiodofstudyofpart-timecourse
– Standardperiodofstudyofcomparablefull-timecourse
Studyingtowards: Plannedendofdegreestudies
Lastofficiallectureinthepresentsemesterison
Firstofficiallectureinthenextsemesterison
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Undersocialinsurancelawyouarenotentitledtomakeapplicationsortakeactionwithouttheconsentofalegalrepresentativeuntilyoureach theageof15.Accordingly,pleaseappendthesignatureofyourlegalrepresentativeifyouhavenotyetreachedtheageof15.Onlythenwillyoubeabletouseourservice.
Iamactingastherepresentative,withpowerofrepresentation/legalrepresentative/caregiverandherebyauthoriseorconsenttothedisclosuresmadeabove.
Name/firstnameoftherepresentative Representative’saddress
Representative’ssignature
Employee‘s pers. no.:(tobecompletedbytheemployer)
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To be completed by the health insurance fund:
Assessment result(forpersonsinsuredwithSBK)/Advice result(forpersonsinsuredwithotherhealthinsurancefunds)
Compulsoryhealthinsurance: Yes,from No
Contributionratetohealthinsurance: General,from Reducedrate,from
Compulsorypensioninsurance: Yes,from No
Compulsoryunemploymentinsurance: Yes,from No
Compulsorylong-termcareinsurance: Yes,from No
Healthinsuranceflatrate(ifstatutorilyinsured): Yes,from No
Pensioninsuranceflatrate: Yes,from No
Group of persons:
Employee(101) Apprentice(102) Trainee(105) Workingstudent(106)
Limitedpart-timeemployment Temporaryemployment(110) Apprentice<€325(121) Accidentinsuranceonly(190)
DateNamePhoneno. Stamp/signatureofSBK
(109)
Confirmation from employer (to be completed by the employer) Wehavecheckedtheemploymentinformationinitem1.Acopyoftheregistrationcertificate/evidenceofinternship/certificateofschoolattendancehasbeenaddedtothepersonnelfile.Weshallnotifyanychangesintheemploymentrelationshipwhichmayhaveaneffectonthesocialinsurancewithoutdelay.
Low-wageemployees:requestforpensioncontributionexemption: No Yes,exemptioneffectivefrom
DateResponsiblePhoneno.Stampandsignature