TRAVEL INSURANCE

POLICY CERTIFICATE
This certificate can be used and presented in case of visa
application in a foreign consulate.

INSURED DATA
FIRST NAME SINCERE
SCHENGEN
SURNAME MUTONI Benefits and limits are listed below

DATE OF BIRTH 2001-08-17

PASSPORT NUMBER PC628588

PERIOD OF COVER REFERENCES

DEPARTURE DATE 2023-11-14 CERTIFICATE NUMBER UAPOMRWA00000147
RETURN DATE 2024-11-13 AGREEMENT NUMBER 7001797

IN CASE OF EMERGENCY CONTACT AXA ASSISTANCE(24/7) ON OUR WORLDWIDE EMERGENCY NUMBER + 33 1 55 92 22 20

INSURED AGE NUMBER OF DAYS PREMIUM AMOUNT (US $)

SINCERE MUTONI 22 366
VAT (18%)
Administration Fee
TOTAL (US $) 490.05

The table of benefits below indicates the different options and limits under the individual travel program of Old
Mutual. You have purchased the SCHENGEN cover option.

BENEFITS AND LIMITS (US $) – RETAIL

BENEFITS BUSINESS HOLIDAY SCHENGEN STUDENT SENIOR INCOMING EAST AFRICA
Eligibility (Age) Up to 75 Yrs Up to 75 Yrs Up to 75 Yrs Up to 30 Yrs Age 76 to 85 Up to 75 Yrs Up to 75 Yrs
MEDICAL & RELATED EXPENSES 300, 000 200,000 80,000 75,000 100,000 120,000 30,000
Medical Transportion, Repat and Evacuation 50,000 30,000 25,000 20,000 20,000 20,000 2,500
Pre-Existing Medical exp (Hospital Admission Longer than 48 hours,
journey less than 30 days 25,000 No Cover No Cover No Cover No Cover No Cover No Cover
Compassionate Emergency Visit 5,000 3,500 3,500 2,000 2,000 No Cover 1,000
Follow-up Treatment in country of residence 2,000 1,000 500 500 500 Not Applicable 200
Daily Hospital Cash Benefits - 1 Day waiting period 350 (35 pd) 250 (25 pd) No Cover 200 (20 pd) 200 (20 pd) 250 (25 pd) No Cover
Emergency Dental Expenses 350 300 300 200 200 300 100
Emergency Optical Expenses 350 300 300 200 200 300 100
Excess on Outpatient Claims 150 150 150 150 150 150 30
ACCIDENT
Accidental Death 15,000 10,000 No Cover 5,000 5,000 10,000 2,000
Accidental Disablement 30,000 25,000 No Cover 10,000 5,000 25,000 1,000
UAP TRAVEL ASSISTANCE
Repatriation of Children 5,000 3,500 3,500 No Cover 2,000 No Cover 1,000
Repatriation of Travel Companion 5,000 3,500 3,500 2,000 2,000 No Cover 800
Burial, Cremation or Return of Mortal Remains 50,000 30,000 25,000 20,000 20,000 30,000 2,400
Travel Delay 200 150 No Cover No Cover 150 No Cover 100
Travel Delay after 12 hours 12 hours No Cover No Cover 12 hours No Cover 6 hours
Legal Expenses 1,000 500 500 500 500 No Cover 300
Cancellation and Curtailment - Excess 150 2,000 1,500 1,000 1,500 1,000 1,500 800

OLD MUTUAL INSURANCE RWANDA PLC.

Grand Pension Plaza | 7th Floor | P.O Box 6644, Kigali, Rwanda |
Tel: +250 788 168 000 | Toll free: 2828 | Email: OMinsurance@oldmutual.rw| www.oldmutual.rw

INSURANCE | INVESTMENT | SAVINGS IN PARTNERSHIP WITH

 BUSINESS HOLIDAY SCHENGEN STUDENT SENIOR INCOMING EAST AFRICA
Consular Referrals Service only Service only Service only Service only Service only Service only Service only
Emergency Accomodation and Travel Service only Service only Service only Service only Service only Service only Service only
Transmission of Urgent Messages Service only Service only Service only Service only Service only Service only Service only
Delivery of Medicines Service only Service only Service only Service only Service only Service only Service only
BAGGAGE - Single Item Limit 25% of benefit amount 1,500 1,000 No Cover 1,000 1,000 1,000 No Cover
Cash and Document (included in luggage) 150 100 No Cover 100 100 100 No Cover
Luggage delay after 8 hours 200 150 No Cover 100 100 100 No Cover
Trade Sample (Excess $150) 1,000 No Cover No Cover No Cover No Cover No Cover No Cover
PERSONAL LIABILITY (Excess USD 200) 150,000 100,000 50,000 No Cover 75,000 No Cover 1,000
HIJACK, HOSTAGE, WRONGFUL DETENTION (12HRS) 7,500 (100pd) 5,000 (50pd) No Cover 5,000 (50pd) 5,000 (50pd) No Cover No Cover
War & Terrorism Covered Covered Covered Covered Covered Covered Covered

As an exception to the General Exclusions related to epidemics and/or pandemics declared by the World Health Organisation, the Beneficiary is
covered under the same terms if He/She falls ill during the trip with an infectious disease including Covid-19. It applies for Medical transportation,
Medical expenses, Cancellation & Curtailment and Body repatriation & Return of mortal remains. Please refer to Terms & Conditions.

SPECIAL PROVISIONS

• The insured recognizes and declares to be informed of the General Conditions as well as the benefits and the
exclusions.
• This certificate cannot be used as a letter of guarantee of payment into public or private medical organization.
• The insured declares not to have scheduled any travel for therapeutic treatment.

IMPORTANT - IN CASE OF CLAIMS

• In case of claim, previously to any action, the insured or any person acting on his behalf must contact AXA Assistance on
+33 1 55 92 22 20 for medical emergencies & for Claims, and inform the :

Agreement Number:7001797
Certificate Number:UAPOMRWA00000147
Surname: MUTONI
First name: SINCERE
Departure date: 2023-11-14
Return Date: 2024-11-13

This Certificate is issued on:2023/10/30

................................................... ...........................................................
Alice Uwase Signature of Insured
Head of Underwriting and Reinsurance

OLD MUTUAL INSURANCE RWANDA PLC.

Grand Pension Plaza | 7th Floor | P.O Box 6644, Kigali, Rwanda |
Tel: +250 788 168 000 | Toll free: 2828 | Email: OMinsurance@oldmutual.rw| www.oldmutual.rw

INSURANCE | INVESTMENT | SAVINGS IN PARTNERSHIP WITH

 The Embassy
The Honorary Consulate

To Whom It May Concern

Confirmation of Travel Insurance For Visa Requirements

We hereby confirm that we have issued a travel insurance cover as per the attached travel insurance certificate for the
person noted below. Our cover is worldwide and meets all Schengen VISA Requirements except for the INCOMING and
EAST AFRICA Options.

POLICY HOLDER SINCERE MUTONI

PASSPORT / ID NUMBER PC628588
POLICY NUMBER UAPOMRWA00000147
COVER PERIOD FROM2023-11-14 TO: 2024-11-13
NUMBER OF DAYS 366
COVER OPTION SCHENGEN
Refer to the Policy Certificate for the appropriate Benefits and Limits.
Note: The INCOMING and EAST AFRICA option are not designed to meet the Schengen Visa Requirements

DATE OF ISSUE 2023/10/30

As an exception to the General Exclusions related to epidemics and/or pandemics declared by the World Health Organisation, the Beneficiary
is covered under the same terms if He/She falls ill during the trip with an infectious disease including Covid-19. It applies for Medical
transportation, Medical expenses, Cancellation & Curtailment and Body repatriation & Return of mortal remains. Please refer to Terms &
Conditions.

The insurance meets all requirements of the regulation (EC) No 810/2009 of the European Parliament and the Council of
13th July 2009.

If you have any queries, please do not hesitate to contact our office.

Yours faithfully,

Alice Uwase
Head of Underwriting and Reinsurance

OLD MUTUAL INSURANCE RWANDA PLC.

Grand Pension Plaza | 7th Floor | P.O Box 6644, Kigali, Rwanda |
Tel: +250 788 168 000 | Toll free: 2828 | Email: OMinsurance@oldmutual.rw| www.oldmutual.rw

INSURANCE | INVESTMENT | SAVINGS IN PARTNERSHIP WITH