Private Health Care

Here are a list of questions that need to be answered so that the correct advice can be given to you. These questions give a broad overview of your present situation taking several important factors in to account, such as your employment status, state of health and family situation. Please answer the following questions so that we are able to offer you the cover that best suits your needs and at the best price. Once you have returned the questionnaire you will be personally contacted to talk through the next steps.

For a free quote please fill in the below:

    Personal Details:

    Address in Germany:

    Address abroad:

    Best form of contact

    Visa / Type of Visa / Duration

    Planned duration of stay in Germany

    Your last/present health insurance



    Income gross/net

    Height / Weight

    Preconditions/Chronic Illnesses


    Tariff Level (Quality level of cover – Standard/comfort/Top)

    Specific Wishes (Alternative medicine/Dental/Vision/Private rooms and doctors in Hospital/etc.)

    Who has to be insured? (Partner/Children)

    If you have other family members who have to be insured with you, please answer the questions above for coinsured persons.

    Other Information:

    I have taken notice of the privacy policy. I agree to the use and storage of my information for the purposes of processing this enquiry. Note: You can revoke your consent for the future by sending an Email at