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Premium Calculation

Insurance period

Departure / starting date Month:  Day:  20 
Return / termination date Month:  Day:  20 
Destination country:

Cover

IPS Primary: cover with medical expenses
  premium US$ 58.00 per month

Additional coverage

Do you wish your policy to cover you for winter and underwater sports activities as well? (extra premium
US$ 8,00 per month)
Yes, I want a coverage for winter and underwater sports activities

Premium overview

Payment

Credit Card Company
Credit Card Number

Personal Details insured

Surname:
Firstname:
Gender: M F
Date of birth (MM-DD-YYYY)
Nationality:

Address in originating country

Street/Housenumber:  
Postal code/City:
Country:
Telephone number:
Cell phone number:
E-mail address:
   
Are you:
student
member of teaching staff
researcher
au pair
other
Name of institution where you are registered or employed:  
Your registration or employee number:

Address in Europe

Street + housenumber:  
Zip code/City:
Country:

General information

Are you currently receiving medical treatment or have you had any medical treatment in the last six months?
yes * no
* If answered 'yes', for which disease were or have you been treated?
Please note that pre-existing conditions are not covered.
Have you ever been refused for an insurance cover, has your insurance ever been cancelled or have special conditions ever been attached to insurance cover for you?
yes * no
* If you have answered 'yes', please give details
Is there anything else you wish to state which may be relevant when assessing this application (such as a criminal conviction in the last 8 years of the applicant or the other persons who will be included under this policy)? This includes offences which have brought you into contact with the police or the criminal justice system (such as questioning or prosecution, a decision not to prosecute or fixed penalties).
yes * no
* If you have answered 'yes', please give details

    

W.B.D. Lippmann Groep BV - Casuariestraat 5 -  2511 VB The Haque, The Netherlands - T + 31 70 302 85 98 - F + 31 70 361 76 10