Follow the steps to fill out the form correctly

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. In section A, provide your personal information. Enter your full name, including any previous names, followed by your date of birth. Next, fill in your address, including street, house number, postal code, and city. Lastly, include your phone number along with the area code.
3. In section B, indicate your voluntary membership. Start by entering the date when your voluntary insurance began. If applicable, also include the end date of your voluntary insurance. Ensure the dates are accurate and formatted correctly.
4. Continue in section B by documenting any interruptions in your voluntary insurance. Record the start and end dates for any interruptions to ensure your insurance history is comprehensive.
5. Next, you'll need to detail the amount of your contribution in section B. Fill in the contribution amounts, excluding any parts for sickness benefits and private insurance contributions. Record the monthly total amount clearly.
6. In section C, you will need to sign the document. Also, include a contact number for any further inquiries and the current date. Make sure your signature is clear, as it validates your submission.
7. Once all sections are completed and reviewed, save your changes. You can then download a copy of the form, print it for your records, or share it as needed.

Start filling out your documents online today and ensure your health insurance is properly managed.