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3ROLĠDGHDVLJXUDUHGHFăOăWRULHvQVWUăLQăWDWHQUVOJ130744997
Travel insurance policy no. VOJ130744997
ÌQED]DFRQGLĠLLORUGHDVLJXUDUHúLvQVFKLPEXOvQFDVăULLSULPHLde asigurare FRUHVSXQ]ăWRDUH$//,$1=ğ,5,$&$6,*85Ă5,6$DVLJXUăSH(Throughout
Terms and Conditions and in the exchange of contractual premium collection, ALLIANZ TIRIAC ASIGURARI S.A. insures)
Nume (Surname): Nica Prenume (First Name): Mihail
&131USDúDSRUW(Serial ID): 1681016080015 'DWDQDúWHULL(Date of birth): 16.10.1968
Tel. (Telephone no.): 723603925 Email (E-mail address): mihailnica68@yahoo.com
Adresa ORFVWUQUMXGHĠVHFWRU(Address: town, street, no., county) : Judet Brasov; Brasov; Str. Strada Carpatilor; Nr. 93; Bl. 1; Ap. 15;
3HULRDGDDVLJXUăULL(Insurance period) De la: (From) 11.11.2022 3kQăOD(Until) 05.12.2022
$FRSHULUHWHULWRULDOă 7RDWHĠăULOHFXH[FHSĠLD5RPkQLHLúLĠDULLGHUH]LGHQĠăD$VLJXUDWXOXL
(Teritoriality) (Worldwide, with exception of Romania and rezidential country of the Insured)
6XPDDVLJXUDWăSHQWUX Cheltuieli medicale 50.000 EUR din care: cheltuieli de repatriere 10.000 EUR; cheltuieli medicale ca urmare a unui puseu acut al unor afectiuni
Asigurarea Medicala: (Sum pre-existente sau boli cronice 1.000 EUR (Medical expenses 50.000 EUR including repatriation expenses 10.000 EUR and medical expenses
insured for Medical Insurance) as a result of acute flare of pre-existing condition or chronic disease 1.000 EUR)
6FRSXOFăOăWRULHL(Travel scope) Turism (Turism) Sport de agrement(Recreational Sport) 0XQFă
(Work)
3ULPDWRWDOăGHDVLJXUDUH (Insurance premium): 103 RON Data emiterii: (Issue date) 07.11.2022
352&('85Ă'(850$7Ì1&$='(85*(1ğĂ PROCEDURE TO BE FOLLOWED IN CASE OF EMERGENCY
În cazul producerii evenimentelor acoperite prin $VLJXUDUHDPHGLFDOă In case of occurrence of any event covered through Medical Insurance, the
$VLJXUDWXOVDXXQUHSUH]HQWDQWDODFHVWXLDWUHEXLHVăUDSRUWH]HXUJHQĠD Insured or his/her representative has to report medical emergency
PHGLFDOăLPHGLDWOD&RPSDQLDGHDVLVWHQĠă immediately to the Assistance Company:
MONDIAL ASSISTANCE GmBH MONDIAL ASSISTANCE GmBH
Pottendorfer Strasse 23-25, A-1120 Wien, Pottendorfer Strasse 23-25, A-1120 Wien,
Tel.: 00 43 (1) 525 03 53, 00 40 (21) 312 22 39 Tel.: 00 43 (1) 525 03 53), 00 40 (21) 312 22 39
VăRIHUHXUPăWRDUHOHLQIRUPDĠLL to provide the following information:
ƒQXPHOHúLSUHQXPHOH ƒ name and surname
ƒQXPăUXOSROLĠHLGHDVLJXUDUH ƒ insurance policy number
ƒQXPăUXOGHWHOHIRQúLDGUHVDODFDUHSXWHĠLILFRQWDFWDWvQVWUăLQăWDWH ƒ telephone number and contact address details from abroad;
ƒPRWLYXOSHQWUXFDUHVROLFLWDĠLDVLVWHQĠă ƒ reason for requesting assistance
úLVăUHVSHFWHLQVWUXFĠLXQLOHSULPLWHGHOD&RPSDQLDGH$VLVWHQĠă and to follow the instructions received from the Company of Assistance;
În cazul producerii evenimentelor acoperite prin Asigurarea Storno, In case of occurrence of the events covered by Storno Insurance, the Insured
$VLJXUDWXOVDXXQUHSUH]HQWDQWDODFHVWXLDYDDQXQЙD&RPSDQLDGH or his/her representative shall notify the Assistance Company within 2 working
$VLVWHQЙăvQWHUPHQGH]LOHOXFUăWRDUHODQXPHUHOHGHWHOHIRQGHPDL days at the above telephone numbers or at the e-mail address
sus sau la adresa de e-mail Daune_AZ_Tiriac@mondial-assistance.at. Daune_AZ_Tiriac@mondial-assistance.at.
În cazul producerii evenimentelor acoperite prin contractul de asigurare, For the events covered through the current insurance contract (except those
DOWHOHGHFkWFHOHDFRSHULWHSULQ$VLJXUDUHD0HGLFDOăɁL$VLJXUDUHD6WRUQR covered through Medical Insurance ans Storno Insurance), the Insured or
$VLJXUDWXOVDXXQUHSUH]HQWDQWDODFHVWXLDWUHEXLHVăDYL]H]H$VLJXUăWRUXO his/her representative has to notify the Insurer in 5 days from his/her return to
vQWHUPHQGH]LOHOXFUăWRDUHGHODvQWRDUFHUHDvQĠDUă the residential country.
$POXDWODFXQRVWLQĠăGHFHOHvQVFULVHvQ&HUHUHDGH$VLJXUDUHIPID,&RQGLĠLLOHGH I have been notified with respect to the Application Form, Insurance Product Information
Asigurare CAV11 úLGHFODUSHSURSULDUăVSXQGHUHFăGDWHOHLQFOXVHvQ&HUHUHDGH Document and Terms and Conditions CAV11 and I declare on my own responsibility the
$VLJXUDUHVXQWUHDOHúLvQFRQIRUPLWDWHFXLQIRUPDĠLLOHGHFDUHGLVSXQDVWIHOVXQWGH dates included in the Application Form are real and in agreement with the information I
DFRUGFXvQFKHLHUHDFRQWUDFWXOXLvQDFHVWHFRQGLĠLL set, therefore, I agree to conclude the insurance contract under this conditions.
3UH]HQWDSROLĠăHVWHvQFKHLDWăvQGRXăH[HPSODUH(The current policy is concluded in two indents.)
ASIGURAT (Insured) INTERMEDIAR (Intermediarry) $6,*85Ă725(Insurer)
NICA MIHAIL CONSULTANT A.A.-BROKER DE ASIGURARE -
REASIGURARE S.R.L.
QXPHVHPQăWXUă(name, signature) QXPHVHPQăWXUă(name, signature)

$//,$1=‫܉‬,5,$&$6,*85Ă5,6$ &DSLWDOVRFLDOVXEVFULVúLYăUVDW94.393.890 lei

6WUDGD%X]HΊWLQUHWDMHOH Înregistrat la ORC sub nr. J40/15882/1994, CUI: 6120740
6HFWRU%XFXUHΊWL5RPkQLD 6RFLHWDWHDXWRUL]DWăGH$XWRULWDWHDGH6XSUDYHJKHUH)LQDQFLDUă
Info Line: +4 021 2019 100 &RGXODORFDWvQ5HJLVWUXODVLJXUăWRULORUúLUHDVLJXUăWRULORU5$017
info@allianztiriac.ro 1 Codul LEI 529900XKNXM9MBH8GS45
www.allianztiriac.ro SR EN ISO 9001:2015