GF Test Upload Switch

Gender*

Male
Female

First Name:*

Last Name:*

Email*

Date of birth:*

I hereby confirm that I instruct FeelSafe to cancel the public insurance (GKK) on my behalf*

Yes

I hereby confirm that I am registered at the public insurance (GKK) for more than 6 months already*

Yes

Please answer the following health questions.

Only when you can answer all questions with "No" we can guarantee the direct online purchase of the Student Health Insurance Basic and Plus and therefore only then you should cancel the public insurance (GKK)

health basic*

Are you currently or have you been treated for one of the following health impairments?*

cancer
diabetes
HIV-positive results
excessive overweight (body Mass Index over 38)
chronic liver disease
chronic inflammable bowel disease
chronic kidney disease
chronic lung disease

Yes
No

health impairments*

Are you currently or have you been treated for one of the following health impairments?*

heart attack
chronic heart disease
vascular disease (e.g. PAOD/peripheral arterial occllusive disease, aneurysm ...)
blood-clotting disorders (also caused by medication)
blood diseases (e.g. haemolyitic anaemia such as sickle cell anaemia)
congenital anomalies (e.g. metabolic diseases, hormone disorders, cleft lip/palate)

Yes
No

health impairments2*

Are you currently or have you been treated for one of the following health impairments?*

autoimmune diseases
neurologic diseases (e.g. multiple sclerosis, Morbus Parkinson, stroke, epilepsy, benign brain tumour, cerebrocranial trauma, paraplegia)
eye diseases which can lead to severe visual impairment (e.g. macular diseases, retinal diseases, glaucoma)
mental illnesses (including mental handicaps, dementia, psychological illness)

Yes
No

Have you had any medical required treatments (inc. drug therapy) or contact to a medical specialist within the last 12 months? (also for any physiological treatments)*

Yes
No

Have you planned any out-patient treatment, in-patient hospital stay or a stay at a health resort or rehabilitation centre, or has such stay been advised by a doctor?*

Yes
No

Are you doing sports professional? (If sport is your main source of income)*

Yes
No

If female: Are you currently pregnant?*

Yes
No

Upload Cancellation Form (required)*

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