Techniker Krankenkasse, 20901 Hamburg

Fachzentrum
Mitgliedschaft/Beiträge

Tel. 040 - 460 66 10 10

Herrn
Michele Murgo Vorgangsnummer
Hausburgstr. 13 308160227726
10249 Berlin
Geschäftszeichen
T960391544

2. April 2024

Missing information on the termination of your membership

Dear Mr Murgo,

Thank you for sending us your documents on 30 March 2024.

We still require some written information from you to process the termination of your member­
ship. We therefore ask you to complete and sign the form and send it back to us. Thank you.

We will be happy to help you if you have any questions. Just give us a call. Please have your
TK eHealth card ready.

Yours sincerely,
Techniker Krankenkasse
1654427167 - 8970534 - 00000000000000
KA306009
506978872811

Techniker Krankenkasse, 20901 Hamburg, versicherung@tk.de

Telefonservice: Mo.- Do. 8 - 18 Uhr, Fr. 8 - 16 Uhr | tk.de
Vorstand: Dr. Jens Baas (Vorsitzender), Thomas Ballast (stellv. Vorsitzender), Karen Walkenhorst
Vorsitzende des Verwaltungsrats: Dominik Kruchen, Dieter F. Märtens
 Michele Murgo
geb. am 11. August 2002

Geschäftszeichen
T960391544

Techniker Krankenkasse
20901 Hamburg

Information about my stay abroad Please tick the appropriate box or fill in
where necessary and do not forget to sign
the form.

Information about my place of residence

I will have a new place of residence starting on 1 0 0 4 2 0 2 4

Day Month Year
H a u s b u r g s t r a ß e . 1 3
Please provide us with your new address in
Street, house no. the foreign country.

Address line 2
1 0 2 4 9

Post code, city

G e r m a n i a

Country
My stay abroad is temporary X
yes no e.g. due to a holiday or job

expected to end on 1 5 0 4 2 0 2 4

Day Month Year

I am planning to return to Germany X
yes no
1654427193 - 8970534 - 00000000000000

I have health insurance cover in a foreign country yes X

no If you have health insurance cover in a for­
eign country, please enclose a certificate of in­
surance.

Contact data for further inquiries

optional information
+ 4 9 1 7 6 1 7 3 8 7 0 8 8

Telephone number
m i c h e l e m u 7 9 @ g m a i l . c o m
optional information
E-mail address
KR306009

By signing this form, you affirm that the

information you provide here is accurate.
2-04-2024
Please inform us of any changes as soon as
possible.
Date, signature (legal representative, if applicable)
We require this personal data (social data) for the purpose of performing our duties properly. The legal bases
for this are Section 284 SGB V [German Social Code Book V] and Section 94 SGB XI [German Social Code
Book XI].
506978872823

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