Assessment of Students and Interns Pursuant to Social Security Law

sent by Ms/Mr Phone number:

Registration no. of
organisation Fax:

1.1. Name / Date of birth /

1.2. Personnel number: Siglum
1.3. Location: Phone number*:
1.4. German Pension Insurance Number (if known):
1.5. Employment from: to: Working days per week: hours per week:
1.6. Monthly income / Registered at university/college since: /
2. Assessment pursuant to Social Insurance Law to be filled in by the student/intern
2.1. You are exclusively employed during school holidays or semester vacations. yes no
2.2. The student is currently on academic leave of absence (not semester vacations) yes no
2.3. You are employed as part of a co-operative study yes no
2.4. You are insured with a social health insurance fund yes no
2.5. The employee attends the following school or is registered at the following
university/Fachhochschule [university of applied sciences and arts/polytechnic]:
Please fill in this part

2.6. The student studies in the academic semester. Estimated date of final examination:
3. For interns:
3.1. You do your internship before, during, or after your studies before during after
3.2 It is a mandatory internship pursuant to the study or examination regulations yes no
3.3 Does this internship exceeds the duty length no yes, as of
4. For graduate students / Bachelor students / Master students:
4.1. You are employed solely to write your diploma thesis / Bachelor thesis / Master thesis yes no
5. Employment during the past 12 months:
From: ____________ to: ____________ hours/working time per week: _ __ / __ __ max 450 Euro yes no
From: ____________ to: ___ ________ hours/working time per week: ____ / __ __ max 450 Euro yes no
From: ______ _____ to: ____________ hours/working time per week: ____ / __ __ max 450 Euro yes no
I will notify my employer of any changes, such as the commencement of another employment or the end of my studies.
I allow TK to save my above-mentioned details until further notice and to use them to inform me – also by phone – about benefits
and services from TK.
Date: Signature Employee:
We need your personal data ("social data") to correctly perform our tasks for you. This is based on Section 284 Sozialgesetzbuch V (SGB V) [Social
Security Code] in connection with Section 206 SGB V or Section 28 o SGB IV and Section 94 SGB XI in connection with Section 50 SGB XI. We
would like to give you information on the protection of your personal data.
*Voluntary details

Information about the assessment of insurance obligation pursuant to social security law Fax to: 040 - 6000-41 14

Compulsory insurance with health insurance / private insurance pension insurance unemployment insurance
accident insurance none
Contribution class: ____________ Group: __________________

Collecting agency: responsible health insurance TK Bundesknappschaft

agency

Non-contributory dependants co-insurance may end due to exceeding the income limit

Date: Signature:
Phone: 040 - 6000 -
Version 1.13 dated 01/05/2015
Assessment of Students and Interns Pursuant to Social Security Law

Information on Completing the Questionnaire

1. Identification particulars and details on your employment to be assessed:

1.1. Your first and last names as well as your date of birth/Phone (optional)

1.2. In case you were already employed as working student or in a so-called mini-job in Germany, you should have
received a Social Insurance ID Card by the Deutsche Rentenversicherung [German statutory pension insurance
scheme] on which is printed the Pension Insurance Number.

1.3. Details on your employment. We can only assess your social security obligation or exemption from social security
correctly if you have correctly completed the form

1.4. Your monthly income from employment and the beginning of your studies. Alternatively, you can indicate your
current academic semester (not semester at university/college). (see point 2.6)

2. Information required for the assessment pursuant to Social Security Law

2.1. Should the periods of employment and teaching overlap, answer NO. Please submit proof of your teaching
periods if you are employed during semester break and/or there is a slight overlapping.

2.2. In case you are on academic leave of absence during employment, please answer YES.

2.3. Co-operative studies combine education at a Fachhochschule [university of applied sciences and arts/polytech-
nic] (with the objective of a degree) and, at the same time, in-house vocational training or continuing vocational
training. Apart from theoretical education, the share of education in vocational training is considerable.

2.4. Under certain requirements, your employer only has different obligations from your statutory or private health in-
surance.

2.5. Name of university/college

2.6. Details on your current academic semester (not semester at university/college). Please always submit the current
enrolment certificate. Please note the date of your final examination, if possible. Otherwise please note the esti-
mated end of your study.

3. Interns:

3.1. When do you do your internship to be currently evaluated: prior to starting your studies, during your studies, or
after passing the final exams?

3.2. In case your internship is mandatory for your studies or exams, please answer YES and submit the relevant
proof.

3.3. It is obligatory to differentiate between a mandatory and a voluntary internship exactly. Please fill in the beginning
of the voluntary subsequent period of your internship.

4. Graduate students / Bachelor students / Master students:

4.1. Provided that you are employed by this company in addition to the work required for your degree, please answer
NO.

5. Employments during the past 12 months:

5. Please list all employments during the past 12 months including the weekly time of work and the working days.
Furthermore we require you to note whether your monthly brut income was more or less than 450 Euro. Please
note ongoing employments too.

Version 1.13 dated 01/05/2015