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