Care Austria Application Form

In order for us to be able to provide you with the most suitable insurance coverage to meet your needs, it is necessary that you fill out the form and answer all questions completely and truthfully then your application will be worked on shortly by a staff member of Care Concept AG.

Within the next one or two working days, you will receive a written message concerning your application.

Policy holder/Contract holder

Policy Holder/Contract Holder

Last Name

Date of birth

Nationality

Adresse

PLZ/Region

Are the policy holder and the insured person identical?

Yes no

Insured Person

Insured person

Last Name

Date of birth

Nationality

Information about your stay in Austria

Residence before starting your trip?

Arraival date in Austria

Country of destination:

Commencement of coverage

Intended duration of your stay in Austria?

Product Selection

Select you insurance plan

Payment methods and Details

Direct debit monthly Bank transfer monthly Direct debit one-off Bank transfer one-off

SEPA Direct Debit Mandate
By signing this mandate form, you authorize the mentioned creditor to send instructions to your bank to debit your account and your bank to debit your account in accordance with the instructions from the mentioned creditor. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited.
Payee: ZK Visassist e.U.
A-1040 Wiedner Hauptstraße 65
Gläubiger-Identifikationsnummer(Creditor ID): AT11ZZZ00000066183

Full name of the bank account holder

BIC

IBAN

Are you account holder?

Yes No

If no, I certify that I am authorized by the account holder to operate the aforementioned account, to express and receive declarations of intention for him and that I will forward all messages in the context of the SEPA direct debit mandate to the account holder

Yes No

Health questions

Insured person height in centimeter (cm):

Insured person Body weight in kilogram (kg)

Have complaints, illnesses, health problems, anomalies and/or the consequences of accidents existed in the last 3 years or still existing (except regular check-ups without findings, common colds/flus or short-term, minor gastro-intestinal diseases)?

No Yes

In the last 3 years, have treatments by doctors/associates of other healing professions (e.g. dentist, alternative practitioner, psychotherapist / psychologist) been carried out on an outpatient basis or in hospitals / health resorts or are such treatments recommended for the future? Please do not indicate any preliminary examinations in which no findings have been made.

No Yes

Have you taken any medication (other than contraceptives) regularly for more than 14 days in the past 12 months?

No Yes

Are there missing teeth in the natural teeth that have not yet been replaced? If yes, please indicate the number. (Complete closure of gaps, wisdom and milk teeth are not considered missing teeth)

No Yes

You confirm that all the information i have provided is complete, thorough and correct. In addition, I am entitled to make all declarations/statements and are fully informed about them.

You confirm that you have read, understood and agreed to the following conditions. At the same time, by clicking here you are confirming that you printed and / or downloaded the following terms and conditions/documents before sending your application:

Explicit statements / Important documents
Terms and conditions health insurance
General terms and conditions

ZK Visassist e.U. is entitled to send my information to Care Concept AG and amend the insurance policy on behalf of the policy holder. The authorization also refers to using the above bank information to buy Care Austria insurance plan.

ZK VISASSIST e.U.

Tiefer Graben 9/14
1010 Vienna

(+43) 650-59 00 459
office@visassist.at

Care Austria application

ZK VISASSIST e.U.

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