Techniker Krankenkasse

20901 Hamburg

Statutory Health insurance as of

Application for membership of Techniker Krankenkasse.

Personal Information

Ms Mr Last name, first name: Ekanayake, Anuruddha

Date of birth: 01/08/1985 Place of birth: Kobeigane Country: Sri Lanka

Nationality: Sri Lankan Pension Insurance Number:

Address: 96, 1st Lane, Alaswatta, Tittawella, Kurunegala, Sri Lanka

Marital status: single married separated divorced since widowed

Details on Previous Insurance

1. I was member of a social health insurance fund in Germany: yes no

If so, from to as member insured dependant

Name and address of social health insurance fund:

Health insurance expired, because

2. I was member of a private health insurance in Germany: yes no

If so, from to as member insured dependant

Name and address of health insurance:

Health insurance expired, because

3. I have not been member of a social health insurance fund or private health insurance
in Germany so far.

4. I cannot provide any information about my previous health insurance.

Please answer questions 30 to 33 as well.

Details on the cost coverage in case of illness (e. g. medical treatment)

5. I am entitled to welfare benefits: yes no

(e. g. social assistance, pension assistance)

If so, from to (Please attach the notification.)

Name and address of

the Sozialamt [local welfare office]:

6. I am entitled to benefits from children and youth care1: yes no

If so, from to (Please attach the notification.)

Name and address of local Children and Family

Court Advisory and Support Service 2:

7. In case of illness, I am entitled to an allowance or medical care pursuant to the rules and
regulations applying to civil servants 3: yes no

If so, from to

Name and address of the authority responsible:

I have an additional private health insurance4: yes no

8. I receive benefits pursuant to the Bundesversorgungsgesetz

[Federal War Pensions Act] or Bundesentschädigungsgesetz
[Federal Indemnification Law]: yes no

If so, from to (Please attach the notification.)

Name and address of the pension office in charge:

1 Kinder- und Jugendhilfe

2 Jugendamt
3 Beihilfe or freie Heilfürsorge
4 This additional private health insurance covers outpatient, inpatient, and dental therapeutic treatment

as well as supplementary sick pack and possibly hospital per diem allowance.
9. I receive health care benefits pursuant
to the Strafvollzugsgesetz [German Prison Act]: yes no

If so, from to

Name and address of the penal institution:

Employment Details

10. I am an employee: yes no

If so, as of

Name and address of employer:

I am in marginal employment (for example: mini-job).

11. I am self-employed: yes no

If so, as of
(Please attach a copy of your income tax assessment.)

I am a company founder and have not yet received any income tax assessment.

I am receiving from the Federal Employment Agency / have applied for at the
Federal Employment Agency

a company formation grant.

a start-up benefit.

(Please attach a copy of the notification of the benefit grants.)

12. I am attending school / university or college: yes no

If so, I am in first academic semester, student identification no.

(Please attach a current certificate of school attendance or a confirmation of student status.)

Name and address of the university / college: University of Oldenburg

I am attending a preparatory lecture at university / college.

13. I am entitled to retirement benefits from statutory pension insurance: yes no

If so, as of Pension Insurance Number

(Please attach a copy of your pension entitlement.)

14. I have applied for benefits at the Federal Employment Agency: yes no

If so, I am entitled to

unemployment benefit

unemployment benefit II

as of
15. Income Details
Note: Please attach proof of your current income (e. g. copies of income tax assessment, bank statement).
Thank you!

Current income:

Earnings from employment: EUR per month

(including mini-job)

Bonus payments: _____ EUR per year

(e. g. holiday bonus or Christmas bonus)

Retirement benefits: EUR per month

Bonus payments: EUR per year

Income from self-employment: EUR per month

Early retirement benefits: EUR per month

Retirement benefits from foreign

statuary pension schemes: EUR per month

Other retirement benefits: EUR per month

Unemployment benefit/unemployment benefit II: EUR per month

Income from letting and leasing: EUR per month

Income from capital gains: EUR per month

Maintenance allowance: EUR per month

(This does not include maintenance allowance for children.)

Other income: ________________________ EUR per month

(type of income)

I do not have an income and make a living from:

I'm spending my savings and a loan for studies
16. Details on my spouse / life partner* as well as joint and dependent children.

I am married / live in a civil partnership*. yes no

My spouse / civil partner* is a member of yes no

a social health insurance fund (e. g. AOK, BKK, TK or other).

We only need the following particulars if your spouse / civil partner is not member of a social health insurance
fund. However, it may be possible that their income will be included in the calculation of the contributions.
Please send us a copy of your proof of income. Thank you.

Income of my spouse / civil partner - EUR per month

Bonus payments - EUR per year

(Please attach the relevant proof of incomes of your spouse/life partner.)

We have 1 joint and dependent children.

Our children are/will be insured with my health insurance: yes no

Our children are members of a private health insurance: yes no

Our children themselves are members of a social health insurance fund: yes no

If your children have their personal private or statutory health insurance cover and have
income of their own, please specify the type of income:

_______________________________________________________________________

*Life partner pursuant to the Lebenspartnerschaftsgesetz [German Civil Partnership Act]

Your income details are also used to calculate the contributions to TK long-term care insurance.

Details in case of return or move to Germany from abroad

Sri Lanka 26/07/2016

17. I have entered Germany coming from on

I have my permanent residence or habitual residence in Germany:

yes, as of no

Please submit your registration certificate, if you registered as a resident after entering Germany. Otherwise
submit a proof of your entry to Germany.

18. I have relocated my permanent residence or habitual residence to

Germany to make use of benefits of health and long-term care
insurances: yes no
19. I am member of statutory health insurance in my expat country
and entitled to benefits pursuant to international or supranational law: yes no

20. I am entitled to private health insurance cover in my expat country

which is also valid in Germany: yes no

21. I have been abroad for more than six weeks and have therefore taken
out private foreign travel health insurance:
(Please attach a copy of your foreign travel health insurance policy.) yes no

22. I was in paid employment / civil service salaries abroad: yes no

If so, as Sector Specialist at United Nations Developement Programme

I received a monthly gross remuneration/pay amounting to 1.000,00 EUR.

I received annual gross bonus payments of - EUR.

23. I was self-employed abroad: yes no

If so, as:

24. I am a German citizen: yes no

(If not, please answer questions 25 to 29 as well.)

25. I have a residence certificate pursuant to European law: yes no

(If so, please attach this certificate.)

26. I have a residence permit for more than 12 months: yes no

(If so, please attach this permit)

27. I have a permit for permanent residence: yes no

(If so, please attach this permit.)

28. I have applied for political asylum: yes no

29. I am entitled to benefits pursuant to the Asylbewerberleistungsgesetz

[German Asylum Seekers Law]: yes no

If not, because
(Please attach the notification.)
Details on previous insurance cover
(This information is only necessary in case you cannot provide any details about your previous health insurance.)

30. Parent's details

Last name, first name of mother: Tennkoon, Yasawathi

Date of birth: 31/01/1954 Place of birth: Polpithigama Country: Sri Lanka

My mother was member of a health insurance in Germany yes no

If so, covered by statutory insurance private insurance

from to as member co-insured dependant

Name and address of health insurance fund: N/A

Last name, first name of father: Ekanayake, Amarawansa

Date of birth: 31/01/1951 Place of birth: Wariyapola Country: Sri Lanka

My father was member of a health insurance in Germany yes no

If so, covered by statutory insurance private insurance

from to as member insured dependant

Name and address of health insurance fund N/A

31. Education

I have attended the following schools (including vocational / professional schools):

from to type of institution name and address of institution

1995 2004 High School Maliyadeva College, Kurunegala, Sri Lanka
2005 2009 University University of Moratuwa, Sri Lanka

32. Employment History

My first employment started on 01/09/2011

Employment history:

from to type of employment employer (name and address)

01/09/2011 15/08/2014 Permanant Brandix Lanka Limited, Sri lanka

16/08/2014 15/08/2015 Permanant Camso Loadstar (Pvt) Ltd., Sri lanka

11/10/2015 30/06/2016 Contract UNDP Sri lanka
33. Details on spouse or civil partner*

de Silva, Achini Date of birth: 25/04/1985

(Last name, first name of spouse / civil partner)

Are you / Were you married? Date of marriage: 27/10/2011 until to the date

Employment history of my spouse / civil partner:

from to type of employment employer (name and address)

03/05/2011 30/06/2016 Permanant Central Bank of Sri Lanka, Sri Lanka

*Civil partner pursuant to the Lebenspartnerschaftsgesetz (German Civil Partnership Law)

In case of any changes, such as a change of income or the beginning of social benefits
payments, I will notify you immediately.

Contact details in case of any queries: Phone number 0094 773077608

or e-mail address: akanuruddha@gmail.com

(This information is optional.)

20/07/2016
Date Signature Signature of legal representative, if applicable
We need your personal data ("social data") to correctly perform our tasks for you. This is based on Sec-
tion 284 Sozialgesetzbuch V (SGB V) [Social Security Code] and Section 94 SGB XI.