TRAVEL INSURANCE CERTIFICATE

REFERENCE: SIA-21-0163179 ISSUING 15/12/2021 PLAN : Going Basic Cov AGENT Hamlat Al Elham

DESTINATION FROM TO COUNTRY OF RESIDENCE TELEPHONE NUMBER

Jordan 15/12/2021 30/12/2021 Lebanon 81174300

FULL NAME DATE OF BIRTH PASSPORT NUMBER

MOUNZER MERHEB 06/11/1986 RL4047420

Contrary to any stipulations stated in the General Conditions, the Plan subscribed to, under this Letter of Confirmation, covers exclusively the below mentioned Benefits,
Limitations & Excesses shown in the table hereafter.
The General Conditions form an integral part of this Letter of Confirmation.
For more info/modification regarding your policy, kindly do not hesitate to contact your authorized agent or e-mail us on info@siassistance.com

BENEFITS SUM INSURED EXCESS

Emergency Medical Expenses Up to $ 65 000 0
Emergency Medical expenses due to COVID-19 (excluding USA,
Up to $ 35 000* 72 hours
Canada, Japan & Australia)
Emergency Medical Evacuation & repatriation Real Cost 0
Repatriation of Mortal remains due to COVID-19 (excluding
Up to $ 15 000* 0
USA, Canada, Japan & Australia)
Repatriation of Mortal remains Real Cost 0

Emergency Dental Coverage Up to $ 300 $ 30

Flight Cancelation Up to $ 150 6 hours

Loss of baggage Up to $ 800 $ 25

Delay of baggage Up to $ 100 12 hours

Trip cancelation (up to 70 years of age) Up to $ 2 000 $ 25

Trip curtailment (up to 70 years of age) Up to $ 300 $ 25

Loss of Passport Up to $ 100 0

Personal Liability Up to $ 10 000 $ 200

Above sums insured are per person & per period of cover

Important Notes:
- This coverage is underwriten by CML
- Upon calling the Alarm Center and claim being processed on direct billing procedure, no deductible shall apply for Insured up to 70 years old
In all cases,deductible shall apply for Insured above 70 years old.
Deductible shall be maintained for all Insured bracket of ages if claims are accepted and processed on reimbursement basis.
(Please refer to Art. C-1 of the General Conditions for all deductibles details)
In case claim is accepted on reimbursement, please refer to the General Conditions.
*Coverage in the USA, Canada, Japan & Australia for Emergency Medical Expenses due to Covid-19 is limited to US $ 20,000 & for Repatriation of Mortal remains due to
Covid-19 is limited to US $ 10,000
- Travelers need to have a PCR negative test dated not more than 72 hours before departing for each trip conducted regardless of the duration of the issued policy.
- The insurance premium as stated in this certificate of coverage must be paid exclusively in US Dollars, as it is due for the risk carrier.

Confirmation Code FOR SWAN INTERNATIONAL ASSISTANCE BROKERAGE S.A.L

For official use, scan the above code to validate this confirmation letter.

In case of emergency or request of assistance,call us on:

PLEASE KEEP THIS LETTER OF CONFIRMATION
WITH YOU AT ALL TIMES. +33 9 70 73 22 47 or +961 9 211 662 or
1-514-448-4417 or send an email to:
Claims must be reported within 48 hours from occurrence of the event request@swanassistance.com
and all related original documents must be submitted to the Company
You will be asked to provide the reference of this letter and/or show this
by the beneficiary within four (4) months maximum.
document. This purchase is non-refundable. Please refer to your receipt. Page 1/1