Coracle - Application for Coracle PRIME

Personal Information

I'm coming to Germany as a

Master Student Bachelor Student

First Name

Last Name

Date of Birth

Place of Birth

Country of Birth

Nationality

Second Nationality

Phone/ Mobile Number

Insurance Type

Current Insurance Type

Name of the Insurance

Blocked Account

Blocked Amount

Enter Your Blocked Amount

Number of Blocked Months

Summary

Blocked Amount for months:

00.00 EUR

Buffer:

EUR

Escrow Fee:

~~99.00 EUR~~
PRIME Offer 59.00 EUR

Total Amount to transfer:

EUR

Are you tax resident in the USA?

No Yes

Are you a Politically Exposed Person?

No Yes

Free Incoming Travel Insurance

ERV Insurance

Intended date of travel (as filled in visa application)

Travel Insurance will cover you from this date till you enroll at your university, at the earliest, Semester Start

Free

Incoming Travel

Insurance for

Coracle PRIME

customers!

Premium ~~68 EUR~~ FREE!
68 Euro is not charged, because it is included in the PRIME package free of charge

Public Health Insurance

University

Speciality

Semester Start

Semesters (I have already studied....)

Identification

Passport Number

Passport

Passport Size Photo

Admit Letter/Enrollment certificate

Do you stay already in Germany

No Yes

Germany Street Name

Germany Building Number

Germany Postcode

Germany City

Germany Phone Number

Comments

Sign here

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

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 68 EUR bonus is a welcome bonus provided by Coracle for becoming Coracle’s insurance customer. By not being one, the Travel Health insurance will cost 68 EUR and I am obliged to pay via SEPA Mandate or other forms.

Coracle Prime Application

Personal Information

Insurance Type

Blocked Account

Free Incoming Travel Insurance

Public Health Insurance

Identification

Agreements