Invullen naam) (invullen adres)



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(invullen naam)

(invullen adres)

(invullen postcode) (invullen woonplaats)


Your reference Our reference Contact person Date

(invullen polisnummer) (invullen naam) 28/01/2017

To whom it may concern,
We hereby confirm that the person named below has Travel Insurance with coverage for assistance, telecommunication costs, extraordinary costs, claims for damage to accommodation, luggage, medical costs, legal aid and accidents(doorhalen wat niet van toepassing is). A confirmation of coverage for assistance, extraordinary costs, medical costs, legal aid and accidents (doorhalen wat niet van toepassing is)is included.
Name : (invullen naam)

Date of birth : (invullen geboortedatum)

Address : (invullen adres, postcode en woonplaats)

Country : (invullen land waar verzekerde woonachtig is)


Name of Insurance : (invullen Lang op reis/Ideale reis/Vakantie-Garantie)

Geographical area of

Insurance cover : (invullen dekkingsgebied Europe/World)

Period of Insurance : (invullen eerste reisdag) until (invullen laatste reisdag)


Summary of coverage for medical expenses:


  • The Insurance includes inpatient and outpatient coverage for both sickness and accident.

  • The medical costs per accident or illness are insured at cost.

  • The medical costs for mental and nervous disorders are insured at cost.

  • The medical costs for hospitalisation are insured at cost.

Upon hospital request a guarantee will be made available by our emergency center SOS International Amsterdam (telephone + 31 20 651 57 77).




  • Medical evacuation is insured at cost.

The evacuation will be arranged by our emergency center SOS International Amsterdam

(telephone + 31 20 651 57 77).



  • Repatriation (of remains) is insured at cost.

The repatriation will be arranged by our emergency center SOS International Amsterdam

(telephone + 31 20 651 57 77).


Yours faithfully,

Europeesche Verzekeringen

Hoogoorddreef 56

1101 BE Amsterdam Z.O.

www.europeesche.nl

This is a literal translation of the Dutch version of the conditions, the latter being the only one binding in case of disputes arising.
Summary of coverage

Assistance

Cost price

Extraordinary costs (incl. Russian Federation)

Only after permission by SOS International



Cost price

(invullen de geldende verzekerde bedragen in geval van IRV of VAKGAR)

Medical costs


  • Incurred outside the Netherlands (incl. Russian Federation)

  • Incurred in the Netherlands

Dental costs

Cost price

€ 1.000,00

€ 250,00

Accidents (incl. Russian Federation)


Riding a motorcycle or motorbike with a cylinder capacity of 50cc or more without a crash helmet

€ 25.000,00

€ 75.000,00

€ 5.000,00


Legal Aid


  • In Europe (incl. Russian Federation, European Part)

- Outside Europe (in case of world-wide coverage), per occurrence. (incl. Russian Federation, Asian Part)

Cost price

€ 5.000,00




Section: Assistance


See the section Extraordinary costs and Medical costs as regards the coverage of costs arising from provision of assistance.

Coverage


Assistance will be given for:

  1. In case of illness, accident or death of the person insured

    1. transport, including necessary (medical) supervision, of the person insured to the Netherlands

    2. despatch of medicine, artificial aids and other aids.

  1. Transferring money in emergency cases. The costs attached to this are also covered. Advances and guarantees will not be given. Money will only be transferred if SOS International is satisfied that it has received sufficient guarantees.

  2. Some of the general exclusions (available on request) do not apply in case of death of the person insured.


Section: Extraordinary costs
Coverage

  1. Payment will only be made for costs incurred in agreement with SOS International and named in paragraphs 2 to 5.3 inclusive, and which are the result of an unforeseen event happening to the person insured and which are necessary and reasonable.

Medical and dental costs as defined in the relevant section are not included in this.

  1. In the event of serious illness or serious accident occurring to the person insured, payment will be granted for:

    1. costs of medical transport, including necessary (medical) supervision, of the person insured to the Netherlands. For transport by air ambulance, the repatriation shall be aimed at saving the life and/or preventing or reducing the expected invalidity of the person insured

    2. additional costs of accommodation and additional travelling costs for the return journey by public transport or by the transport that the trip was made with, for the person insured, and if necessary to give assistance, for 1 travelling companion

    3. additional costs of travel and accommodation during the return trip by public transport of other persons insured also travelling, if the person insured who was affected was the driver of the vehicle by which the trip was made and there is no one to replace the driver in the travelling group

2.4 travel costs to visit the person insured in hospital using public transport or the vehicle by which the trip was made, for persons insured or 1 travelling companion. The maximum payment is € 250.- per occurrence

2.5 costs of travel and accommodation for 1 person to give necessary assistance, if the person insured is travelling alone or when the person insured is taking care of insured children under the age of 16 or insured physically or mentally disabled persons. During the trip and stay this person may derive the same rights of this insurance policy as the person insured

2.6 despatching costs for medicines, artificial aids and other aids. Costs of customs duties and return freight are not included in this.


  1. In case of death of the person insured, payment will be granted for:

3.1 costs of transporting the corpse to the Netherlands or costs of burial or cremation locally including costs of travel and accommodation in the event of the coming over of housemates and family members. The payment made in the event of local burial or cremation can never exceed the cost of transporting the corpse to the Netherlands

3.2 additional accommodation costs and additional costs of the return trip by public transport or the vehicle by which the outward trip was made, for persons insured travelling in the group

3.3 travel costs in the Netherlands to and from the place where death occurred and costs of accommodation there, for a maximum of 2 people. This coverage is only valid in case death occurs in the Netherlands.

3.4 travel and accommodation costs for 1 person to support an insured family member when there is no family member present in the touring group. During the trip and stay this person may derive the same rights from this insurance policy as the person insured

4. In case of return to the place of residence in the Netherlands of the person insured due to an occurrence as defined in 4.1 to 4.2 inclusive, once payment will be granted for additional travel costs of, and additional accommodation costs during the return trip to the place of residence, as well as any return trip to the original travel destination within the original period of travel of the person insured.


    1. To be present at a funeral or cremation of housemates, family members of the 1st or 2nd degree or if these people are in mortal danger.

4.2 Material damage (damage to objects/material things) of private property, rented house, or the company he is working for, which makes his present urgently required.

  1. In addition, payment will be granted for:

    1. costs of tracking down, rescuing or saving the person insured by an authorised body

5.2 additional costs of travel and accommodation in case of missing the original date of the return trip, due to a forced stay abroad as the result of an avalanche, mountain slide, fog, forces of nature, abnormal snowfall, strike by transport companies providing the services used for the return trip

5.3 The additional costs as mentioned in this section that the person insured has to make as a result of an occurrence as mentioned in this section, that happened to a travelling companion. Payment will only be granted if the travelling companion has his own travel insurance which does not provide coverage for the costs that are made by the person insured.



  1. Some of the general exclusions are not applicable in the case of tracking down or death of the person insured.



Specific exclusions


  1. No payment will be granted for costs arising in connection with an illness, medical disorder or physical defect for which the person insured was already being treated abroad before the trip started, or in case the person insured went on the trip with the aim, or as one of the trip's aims, of undergoing treatment abroad.



Section: Medical costs




Description of terms


In the policy and conditions the following terms are taken to mean:

  1. medical costs: the medically necessary costs of:

    1. fees for doctors and for their treatments, examinations, medicine and bandage material

    2. hospitalisation and hospital operations

    3. transport to and from the place where medical treatment was being given, in the country where the person insured was at the beginning of the transportation.

1.4 first prostheses, on the basis of the Nederlandse Orthobandatarief (Dutch Orthoband Rate) and elbow crutches or auxiliary crutches, which are necessary due to an accident as defined in the section Accidents.

  1. dental costs: the medically necessary costs of fees of doctors and/or dentists for dental treatment on the natural set of teeth and of medicine prescribed by them and for X-rays necessary for the treatment.



Coverage


  1. Payment will be granted for medical and dental costs incurred abroad as long as the coverage is in force, but only until the 365th day from the start of the treatment and only if the treatment cannot be delayed until return to the Netherlands.

    1. In addition, payment will be granted for medical and dental post-treatment costs incurred in the Netherlands, but only until the 365th day from the start of the treatment abroad and with a maximum of the insured amounts, if the person insured can show that treatment started abroad while the coverage was still in force

Payment for dental post-treatment costs will only be granted if the costs are a result of an accident covered as defined in the section Accidents, if the person insured can show that the accident took place while the coverage was still in force.

    1. Payment will be made according to the class of the medical Insurance of the person insured in the Netherlands, or, if this Insurance does not exist, to the lowest existing class in the Netherlands.

    2. The deductible amount per person insured occurrence is € 75, - (Only applicable if the name of Insurance is Lang op reis).

Specific exclusions

  1. No payment will be granted for costs:

4.1 arising in connection with an illness, medical disorder or physical defect when the person insured was already being treated for it abroad before the trip started or in case the person insured went on the trip with the aim, or as one of the aims, of undergoing treatment abroad

    1. which, it was already clear from the beginning of the trip, would be incurred during the trip

    2. of medical and dental treatment carried out in a country of the nationality of the person insured, as a result of illness, medical disorder or physical defect which already existed before the trip was started or was showing symptoms

    3. if the doctor, dentist or hospital is not recognised as such by the authorised bodies.


Specific obligation

  1. To guarantee the quality of medical treatments and the co-operation with hospitals and doctors, SOS International, Europeesche and Euro-Centers have the right to decide in which hospital and by which doctor the person insured will be treated.

Section: Accidents




Description of terms


In the policy and conditions the following terms are taken to mean:

  1. accident: a sudden and direct effect of an external force, which results in a bodily injury which, can be medically diagnosed.

The following may also be regarded as an accident:

    1. frostbite, drowning, sunstroke, suffocation

    2. exhaustion, starvation, dehydration and sunburn caused by accidentally becoming isolated

    3. acute poisoning other than through food, stimulants and medication

    4. becoming infected by germs as a result of an involuntary fall into water or other substance

    5. wound infection or blood poisoning in connection with an accident

    6. complications and deterioration as a result of first aid or necessary medical treatment in connection with an accident

    7. spraining, dislocation, laceration of the muscles and tendons, suddenly occurring, whose type and location can be determined medically

1.8 injury resulting from substances or objects unintentionally entering the digestive tract, bronchial tubes, eyes or ears.

  1. No type of hernia will be regarded as an accident; neither will germs entering as a result of a bite or a sting from an insect.



Coverage


  1. In case of death of the person insured directly and exclusively caused by an accident, the amount to be paid out in the event of death, as laid down in the summary of coverage, will be paid out. Any previous payment because of permanent invalidity will be deducted from this.

    1. In case of permanent invalidity of the person insured directly and exclusively caused by an accident, payment will be granted on the basis of a percentage of the amount to be paid out in the event of permanent invalidity, this percentage being equal to the degree of permanent invalidity, not taking the profession or hobby of the person insured into account. This percentage will be determined in accordance with the most recently published "Guides to the Evaluation of Permanent Impairment" of the American Medical Association (AMA), completed with the Dutch guidelines for the determination of invalidity at neurological complaints of the Nederlandse Vereniging voor Neurologie (NVvN) (Dutch Association for Neurology), which may be examined at the offices of Europeesche.

3.2 In the case of more than one accident at the same time, the total payment will not exceed the insured amount to be paid out in the event of total permanent invalidity.

3.3 If the consequences of an accident are worsened due to a sickly or abnormal physical or mental constitution, the payment will not be higher than would have been paid out if the accident had happened to a completely able-bodied and healthy person.

3.4 If an existing permanent invalidity is worsened by an accident, payment will be granted according to the difference in degree of invalidity before and after the accident.

3.5 The degree of permanent invalidity will be determined as soon as, in the opinion of the medical service of Europeesche, the condition can be said to be unchanging. If this is not the case within two years after the date of the accident, the degree of permanent invalidity will be determined on the ground of the definitive degree of invalidity to be expected according to the medical reports.

3.6 If, before the degree of permanent invalidity can be established, the person insured dies as a result of:

- the accident, Europeesche does not have to make any payment for permanent invalidity

- any other reason than the accident, the right to payment will continue to exist. The amount of the payment will be determined by the definitive degree of invalidity that, according to the medical reports, would have been expected to result if the person insured had not died.

3.7 If the degree of permanent invalidity can still not be determined definitively on the 365th day after the accident, Europeesche will pay interest on the payment, after any advance payments have been deducted from the payment, from this day to the day when the degree of invalidity can be definitively determined. The interest rate will be equal to that on the last Dutch government bond loan, issued before the above-mentioned 365th day, the maximum interest rate, however, being 8%.



Specific exclusions

  1. No payment will be granted for accidents:

    1. caused or partly caused by a sickly or abnormal physical or mental condition of the person insured, unless this/these is/are a result of an accident for which this Insurance policy has already provided cover

    2. occurring as a result of practising combat sports, rugby, cycle races and horserace

4.3 occurring as a result of practising winter sports other than these: alpine skiing, biathlon, cross-country skiing, mono skiing, tobogganing, ice-skating, ski-bobbing, ski-sailing, sleigh riding, snow boarding, surf skiing, swingbo and ice-sailing (only applicable if the name of Insurance is Lang op reis).

4.4 Ice hockey remains excluded, as does the preparation and participation in competitions other than the so-called Gästerennen (races for guests) and Wisbiwedstrijden (Wisbi-competitions) (only applicable if the name of Insurance is Lang op reis).

4.5 occurring during mountaineering, apart from those on paths or ground, which even an unpractised person could negotiate (only applicable if the name of Insurance is Lang op reis).

Multiple Insurance policies


  1. If multiple Insurance policies have been taken out with Europeesche to the benefit of one-person insured, the liability of Europeesche is limited as follows. If higher amounts are insured a proportionate part of the premium will be returned at request.




    1. Payment in case of death:

  • general € 125,000.-

  • underwater or winter sports € 12,500,-

  • riding a motorcycle or motorbike without a crash helmet € 2,500.-




    1. Payment in case of permanent invalidity:

  • general € 175,000.-

  • underwater or winter sports € 50,000.-

  • riding a motorcycle or motorbike without a crash helmet € 2,500.-


Section: Legal aid
Coverage

The DAS (Dutch Legal Aid Insurance Company) will grant legal aid and will reimburse the costs involved up to the amounts given in the summary of coverage in accordance with the provisions laid down in its General Conditions which, moreover, apply to this agreement. These conditions are available upon request.


The DAS will grant legal aid as defined in 1 to 4 inclusive for events in connection with the trip, to the persons insured and their relatives left behind, if they can establish a claim for maintenance.

  1. Legal aid for redress

Legal aid for the redress of the person insured against a liable third party for damage/losses caused by the third party to the person insured or to his/her property.

  1. Legal aid for criminal trials

Legal aid for criminal trials instituted against the person insured, unless it is or could be a matter of a punishable act, which testifies to intent or criminal intention or to the breaching of fiscal regulations (including customs regulations).

  1. Legal aid for contracts

Legal aid for disputes regarding agreements entered into by the person insured and directly related to the trip, as long as the amount concerned is at least € 125. -.

  1. Security sum

4.1 The advancing by DAS of a security sum to a maximum amount of € 12.500, - per occurrence if a foreign governmental body, with reference to a covered criminal case, demands a sum as security for the release of the person insured or for the release of his/her belongings.

4.2 By accepting the advancement made by DAS, the person insured irrevocably authorises DAS to dispose of it as soon as it will be released and accepts the obligation to give full co-operation to get the advance back.



4.3 The person insured shall repay the advance as soon as possible but in any case within 1 year after it was given.

Specific exclusions


  1. No legal aid will be granted if the claim of the person insured results from, or is connected with, his/her ownership of, possessing of, keeping or buying/selling of, motor vehicles (including motorcycles) and/or trailers.



VTPO 29/10/2002


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