CEU- register - Feelsafe

Personal Information

Gender

Male Female

First Name:

Last Name:

Street (Address in Austria)

House Number

Door Number

Postal Code

City

Citizenship

Date of birth:

E-Mail Address

Phone number (in case of emergency)

I hereby confirm that I am a recent CEU Student / Faculty / Staff / Researcher

Yes

Start Date of Insurance Period:

You can choose the start date of your insurance (always the 1st of the month).

If you want to be insured immediately, please chose the current month*.

*If this date is in the past the insurance period will start with this date and you have to pay premium for the whole month.

Insurance coverage (payment for expenses for medical treatment) will start with your insurance confirmation via e-mail (1-3 working days) and your selected start month.

Choose start date of insurance:

Data Protection Policy

The legally binding language of all documents and information is German! If you have any questions regarding the data protection policy, please get in touch with us.

Please download and read the data protection policy:
Data Protection Policy*
Data Protection Policy of Website*

➢ I hereby confirm that I have downloaded, read and accepted both of the data protection policies

1) When closing the contract or changing the contract, UNIQA as the insurance provider is allowed to collect my health data from doctors or medical insitutions (page 10); Bei Vertragsabschluss oder einer Vertragsänderung darf UNIQA meine Gesundheitsdaten bei Ärzten oder Krankenanstalten einholen (Seite 10)

Yes

2) In case of an insurance claim, UNIQA as the insurance provider is allowed to collect health data from 3rd parties in order to examine my claim. (pre-authorization) (page 11); Nach einem Versicherungsfall darf UNIQA meine Gesundheitsdaten bei Dritten einholen und prüfen, ob ich Anspruch auf Leistung habe (Vorausermächtigung) (Seite 11)

Yes

3) In case of an insurance claim, UNIQA as the insurance provider is allowed to collect my health data for the direct billing with the health-provider (page 12). Nach einem Versicherungsfall darf UNIQA meine Gesundheitsdaten zur Direktverrechnung mit dem Gesundheitsdienstleister einholen (Seite 12).

Yes

Bank Details:

Please enter your European Bank Account.

The payment will be withdrawn from your account automatically.

Bank Name

IBAN Code (20 digits)

BIC Code

Payment method – Direct Debit

SEPA-Direct Debit Mandate (Authorization to collect the receivables via SEPA Direct Debit)

I/We allow the named recipient of payments to withdraw payments from my/our bank account via SEPA-Direct Debit.

In addition, I/we authorize my/our credit institution to transfer the claims made by the named recipient of payments from my bank account via SEPA-Direct Debit.

I/We can request within eight weeks from the debit date a refund of the charged amount. The agreed upon with my/our credit institution conditions are valid in this case.

IBAN
Payment recipient:

UNIQA Österreich Versicherungen AG
Creditor-ID: AT10AT00000001017
A-1029 Wien, Untere Donaustraße 21

Payment method confirmation

I hereby confirm the payment method

2. Your Product:

Extend your CEU insurance
Insurance provided by: UNIQA

Your Price:

0 – 17 years: €41.03 / month
18 – 27 years: €61.01 / month
28 – 35 years: €76.99 / month
36 – 55 years: €129.28 / month
56 – 70 years: €274.20 / month

Legal:

The legally binding language version of all documents and information is German. Documents and information given in English shall be only of an informative nature!

General Terms and Conditions of Insurance*
Terms and Conditions of CEU Insurance (German & English in one document)*
Distribution & Withdrawal Information*
Factsheet (German)*

➢ I hereby confirm that I have downloaded and accepted all terms of insurance

Privacy Statement*

I hereby confirm that I have downloaded and read the privacy policy

Extend your CEU Insurance

Personal Information

Start Date of Insurance Period: