CEU Family Co-Insurance

Personal Information
Gender*
- Male
- Female
First Name:*
Last Name:*
Street*
House Number:*

(e.g.: Mariahilferstrasse 100/6 --> 100 is the house number; 6 is the door number)
Door Number:*

(If you don't have your door number yet, please put "1")
City*
Postal Code:*
Citizenship*
Date of Birth*
DD slash MM slash YYYY
E-Mail Address:*

Please note: Please don't use a YAHOO e-mail address. For some reason our confirmation e-mails get blocked by their SPAM detector.
Optional: Your Phone number
I hereby confirm that I am a family member of a current CEU Student*
- Yes
- No
Name of the family member who is a current CEU Student*
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:*

Personal Information