Information about insurability

Dear Mr. Karaca,

at the insurance number CC209034573 for you has been taken out an insurance for persons who
want to further improve themselves abroad. You are only insurable within the tariffs Care College
Basic, Care College Comfort and Care College Premium, if you are only going to stay abroad
temporarily and education/qualification is the main reason for your stay.

If you have to call on the insurance’s benefits, we need appropriate proof from you. If you have to call
on a doctor’s services for the first time, please send this pre-printed form filled in and signed together
with the requested documents to:

Care Concept AG • Leistungsabteilung • Postfach 30 02 62 • 53182 Bonn

Without the proof mentioned above, there cannot be a conclusive handling at our house. If the free
spaces for answering the questions should not be enough, please use the back side!

Best regards
Care Concept AG

Please let us know, from when until when, in which institution and for which purpose you participated on further
education since arriving in Germany or Austria respectively since the beginning of your stay abroad as a pupil,
student or trainee.
From / until School / university/institution

Important: Please enclose the relevant certificates of attendance!

If you have already a registration for further education please also submit a copy of them. As a participator of
working-holiday-programmes please transmit an official confirmation (e.g. a visa)

Which nationality do you have? (if necessary please name several)?

Please give us your principal residence in your home country (complete adress)!

When do you expect to return to your home country?

What is the main reason for your stay in germany respectively abroad?

I affirm, that my above-mentioned details have taken place truly and completely. To me it is known,
that incorrect or incomplete details may result in the loss of the insurance cover. I have taken the
references after § 28 exp. 4 of the Insurance Act (see next page) to the knowledge.

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Place / date Sign of policyholder / insured person

Fragebogen zur Versicherungsfähigkeit

Information about insurability

Information on the consequences of breach of duties after the

insured event

Information under Sec. 28 para. 4 VVG

Duties to provide information and assist in clarification

On the basis of the contractual documents entered into with you, we may demand from you
after the occurrence of the insured event that you provide us with all information that is
necessary to ascertain the insured event or the scope of our liability (duty to provide
information) and to provide us with all details that serve to clarify the matter (duty of
clarification) to enable us to properly assess our liability. However, we may also demand that
you provide us with supporting records / documents provided that such demands are
reasonable.

Loss of benefits

If, contrary to the contractual agreements, you wilfully provide no information or incorrect
information or wilfully fail to provide us with the supporting records / documents that we
request, you will lose your entitlement to the insurance benefits. If your breach of these
obligations is based on gross negligence, you will not fully lose your entitlement, but we may
reduce the benefits in proportion to the seriousness of your fault. There will be no reduction if
you prove that you have not been grossly negligent in infringing the obligations.

Despite a breach of your obligations to provide information or assist in clarification or provide

supporting records / documents, we will still be obliged to pay benefits insofar as you can
prove that the wilful or grossly negligent breach was not the cause of the ascertainment of
the insured event or the ascertainment of the scope of our liability.

If you fraudulently breach the obligation to provide information, to clarify matters or to provide
supporting records / documents, we will in every case be released from our liability to pay
benefits.

Note: If a third party and not you yourself is entitled to the benefits under the contract, such
third party must also provide information, assist in clarifying matters and provide supporting
records / documents.

Fragebogen zur Versicherungsfähigkeit