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Name:
e-mail:*
Age: /years/
Address:
Phone Number :
Destination?
Number of days?
Purpose of the travel?
Preferable insurance sum:
Please let us know if you prefer an insurance company:
Covered risks:
1.

2.


3.
4.

5.
6.
7.
8.
9.

Expenses for emergency medical treatment, necessitated by an accident or acute illness.
Expenses for medical transportation and repatriation, necessitated by an accident, acute illness or death.
Rescue expenses.
Death or permanent disability as a result of an accident.
Emergency dental treatment.
Theft and loss of personal luggage.
Theft and loss of personal documents.
Personal liability abroad.
Legal expenses.

Please list the risks which you want to be covered from 1 to 9:
 





 

 
   
 
 
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