Allianz Insured Patients with NO TAJ Card

Patient Data – Allianz

Allianz World Wide Care Insurance will be accepted as payment if correct Policy Information is given.

I have my Allianz Policy Number and can upload a Copy of my Allianz Card / Policy (recommended)

I have my Allianz Policy Number but can not upload a Copy of my Allianz Card / Policy now

Allianz Policy Number – 9 digits after P – Example: P001234567

Upload a Copy of your Allianz Card / Policy Copy!

Choose File (pdf, jpeg, jpg, png, bmp, gif)

Passport, Driver License, Local Residence Permit or Country’s National Identification Card Number.

Upload a Copy of the Data Page of your Passport or both sides of any other types Identification Cards!

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Family (Last) Name

Given (First) Name

Birth Name. Is your Name now the same that you had on your Birth Certificate?

Yes, my name is the same that I had at Birth.

No, I had a name change since Birth due to marriage, voluntarily or for other reasons.

Birth Name (Family)

Birth Name (Given)

Mother’s Maiden Last Name

Mother’s Maiden First Name

Gender – in Hungary only Male or Female Genders are officially recognized.

Male

Female

Place of Birth – Country

Place of Birth – Town, City

Date of Birth, Year-Month-Day

Permanent (Home) Address

Street Name and Number

Additional Information about Address (e.g. c/o)

City, Town

State, County, Region

Zip (Postal) Code

Country of Permanent (Home) Address

Private Email Address that you want to use for Urgent and Confidential Communication.

Private Mobile Phone number

Employer’s Phone/Mobile Number

Employer’s Email Address

Do you work on a River Cruise Ship?

Yes

Your Job, Position, the Type of Work you do

The Name of the River Cruise Ship?

River Cruise Ship’s Phone/Mobile Number

River Cruise Ship’s Email Address

Other Important Information you would like us to know. Optional field.

Additional File Upload – Optional

Choose File (pdf, jpeg, jpg, png, bmp, gif)

I have read and agree to the Terms and Conditions and Privacy Policy. I particularly agree that no refunds may be given for cancelled services or in cases when I was not available for the requested and scheduled visits, according to the Payment Terms and Conditions.

Email Address to Confirm Submission of this Form

Signature – Type your full name here as the first step to confirm your Identity. IMPORTANT! After you Submit the Form here you have to open the message sent to your Email and Click on the “Confirm Submission” Button.