Coracle - Application for Coracle PRIME

Date of Birth

Place of Birth

Country of Birth

Nationality

Second Nationality

Phone/ Mobile Number

Blocked Amount

Enter Your Blocked Amount

Number of Blocked Months

Summary

Blocked Amount for months:

Buffer:

Escrow Fee:

00.00 EUR

EUR

PRIME Fee
59.00 EUR~~99.00 EUR~~

Total Amount to transfer:

EUR

Are you tax resident in the USA?

No Yes

Are you a Politically Exposed Person?

No Yes

Free Travel Health Insurance

Intended date of travel (as filled in visa application)

Premium ~~58 EUR~~ FREE!
58 Euro welcome bonus in the form of free Travel Insurance for becoming Coracle’s Health customer

The Travel Insurance will cover you from this date until you enroll at your university, at the earliest, semester start.

Public Health Insurance

University

Speciality

Semester Start

Semesters (I have already studied....)

Identification

Passport Number

Passport

2. Photo ID Front & Back (national ID, driving license, etc.)

Admit Letter

Passport Size Photo

Do you stay already in Germany

No Yes

Germany Street Name

Germany Building Number

Germany Postcode

Germany City

Germany Phone Number

Germany IBAN

Agreements

By ticking the box, I confirm that I read, understand, downloaded and agree to the:

Terms of business and data protection of Coracle GmbH and Lemon Way

Distance Act and Revocation Right

Depositor Information

Blocking Agreement and Information Providing Agreement

I agree with the issuance of a SEPA direct debit mandate for chosen Insurance Company.

consumer information and CORACLE broker mandate and I hereby confirm that I give my full consent.

I Understand that the 58 EUR bonus is a welcome bonus provided by Coracle for becoming Coracle’s Health customer. By not being one, the Travel Health insurance will cost 58 EUR and I am obliged to pay via SEPA Mandate or other forms.

Coracle PRIME

Coracle Prime Application

Personal Information

Blocked Account

Free Travel Health Insurance

Public Health Insurance

Identification

Agreements

Our Offer

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