10C , Nelson Mandela Street, Banjul, The Gambia, P.O.

Box 277, Tel: +220 4222476, Fax: +220 4222475

RC, 28 - 1997
VAT Reg. No. 29142 Website: www.prime.gm TIN No. 0710010304

TRAVELLERS PERSONAL ACCIDENT & EMERGENCY MEDICAL EXPENSIVE INSURANCE POLICY

POLICY No.: KM01SCH002013 - 00045 APPLICATION No: 0002023

Whereas The Insured named in the schedule, hereto being desirous of insuring in the manner hereinafter mentioned with Prime Insurance
Company Ltd. (hereinafter called the Company) has made a proposal and declaration which it is agreed shall be the basis of this contract and has paid
to the Company the premium stated herein as the consideration for the said insurance for the period set forth in the said schedule.
Now therefore, this policy witnesses
that during the said period the Company shall subject to the terms and conditions hereinafter set out and any endorsements hereon, insure the Insured
Against bodily injury and or death and indemnify the Insured against loss and damage (where the event giving rise to the injury or loss or damage
(where the event giving rise to the injury or loss or damage occurs during the subsistence of this policy) all as hereinafter set forth.

POLICY HOLDER NKIRI JOHN

ADDRESS SERREKUNDA
BANJUL THE GAMBIA
OCCUPATION BUSINESS

THE INSURED MUSTAPHA DARBOE DATE OF BIRTH 15TH NOVEMBER, 1979

PROFESSION BUSINESS PLACE OF BIRTH EYUMODJOCK
LOCATION SERREKUNDA NATIONALITY CAMEROONIAN
OVERSEA CONTACT JAPAN PASSPORT No. AA449018

DESTINATION JAPAN NET PREMIUM 695.65

TRIP DURATION 30 DAYS VAT 104.22
FROM 1st DECEMBER, 2023 TO 31th DECEMBER, 2023
TRAVEL MEANS AIR TOTAL PREMIUM 800.00

BENEFITS LIMITS (EUR) DEFINIION/EXCEPTIONS

EMERGENCY MEDICAL EXPENSES 30,000 EMERGENCY MEDICAL EXPENSES means: Unforeseen medical condition that
PERSONAL ACCIDENT 30,000 arises during your medical travel requiring urgent medical treatment
REPATRIATION OF MORTAL REMAINS 3,000

What you are not covered for under this policy:

1. You have been diagnosed as suffering from a terminal illness
2. You have been receiving in-patient treatment or waiting for treatment
3. You are playing to have medical treatment during your journey
4. Any condition you were receiving regular treatment or advice for at the time you
made travel arrangement and at the time of your journey
5. Any Pre-existing medical condition that you may be suffering from
6. Pregnancy or childbirth

I declare and warrant that I am in good health and that I have no physical defects or infirmities, that
PRIME INSUR
IN Witness whereof this policy has been signed
ANCE
I am between the age of 18 and 65. I have not withheld or concealed anything affecting this insurance This Date of 10th November, 2023
COMPANY LIM
and agree that this declaration shall be the basis of the contract between me and ITED
PRIME INSURANCE COMPANY LIMITED Examined by:……………………………………….
DATE:…………
Signature of the Insured………………………………………………………. …….
For and on behalf of PRIME INSURANCE COMPANY LIMITED

Conditions: See Overleaf