lOMoARcPSD|16248954
INSURANCE CONTRACT FOR P E R S O N S TRAVELING UKRAINE
( M e d i c a l e x p e n s e s ins urance)
Kyiv 27.07.2021
This Offer is an o昀 케cial proposal of the Additional Liability Company " Euroins Ukraine IC "
(hereinafter referred to as the Insurer), addressed to legally competent individuals, to enter
into a Voluntary Health Insurance Contract (continuous health insurance), (accession).
This Contract of voluntary medical expenses insurance, hereinafter — the
Contract/Insurance Contract, is concluded in accordance with the license of the National
Commission for State Regulation of Financial Services Markets for the right to insure
medical expenses issued on the basis of Order No. 2696 dd. 25.10.2016 and the Rules of
voluntary insurance of medical expenses of illness, registered by the State Commission for
Regulation of Financial Services Markets of Ukraine on 26.01.2007 (hereinafter - the
“Rules”)
This Insurance Contract consists of two parts of the Insurance Policy and the Offer (Annex
№1).
I n s u r a n c e policy № 0 2 0 4 3 8 С1 9 -0 0 2 о т 27.07.2021
1. I nsurer PJSC “Euro ins Uk ra ine IC”, EDRPOU code 22868348, Certi昀 椀cate of registration of a 昀
椀nancial
institution series СТ No. 236 dd. 21.08.2004, registration number 11100923, issued on the basis of the
decision of the Financial Services Commission No. 1224 dd. 24.06.2004 , current account
UA033802690000026501056200817 in JSC CB “PRIVATBANK”, represented by the Chairman of the
Management Board Nikolov Yanko Georgiev and the Deputy Chairman of the Management Board
Yakovenko Andrii Valeriiovych acting on the basis of the Charter location: 03150, Kyiv, 102, Velyka
Vasylkivska Street, tel. + 3 8 044 247 44 77, e-mail address
2. Policyholder Full name ALQAHTANI ABDULLAH Phone number +966554222524
Address Saudi Arabia ( ةيبرعال ةكلممال Date of birth 09.02.1998
)ةيدوعسال
3. B e n e 昀
椀ciary Unaasined
4. Pl a ce of the Ukraine
C o ntra ct validity
5. Validity fro [29.07.2021] to [08.08.2021]
m
The Insurance Contract comes into force from the moment indicated as the Contract commencement date, but not earlier than 00
hours 00 minutes of the day following the day of receipt of the insurance premium in full to the account of the Insurer, or
following the day of paying the insurance premium through other payment systems that are allowed by the legislation of Ukraine
and which are introduced by the Insurer.
6. S u m insured E U R 30,000 E U R per insured p e r s o n
7. I n s u r a nc e rate 0.50052%
8. I n s u r a nc e 500.52грн.
premium
9. E v e n t s insured :
Voluntary insurance of The insured event is the fact that the Policyholder (Insured Person) receives medical services, namely
medical expenses the provision of ambulance and/or urgent (emergency) inpatient medical care, provision of
diagnostics and medication, the need for which arose as a result of an acute illness, including as a
result of the coronavirus infection C OVI D-2019.
10.Persons insured:
Full n a m e D a t e of birth Passport Phone number
ALQAHTANI ABDULLAH 09.02.1998 Y887514 +966554222524
, lOMoARcPSD|16248954
11.Total sum insured: [100000* number of insured]
13. Total insura nce p r e m i u m 30,000 EUR
14. S i g n a t u r e of the I n s u r ed 500.52 грн.
Upon the occurrence of an insured event, you must immediately contact the assisting
company Euroins Ukraine by calling tel. 0 8 0 0 5 0 1 0 0 1
Annex №1 to the Insurance Contract for Persons Traveling to Ukraine
1. The subject of th e contract
1.The subject of the Contract is property interests that do not contradict the Law and are
related to the life, health and ability to work of the Insured (Insured Persons).
2.Insured persons — individuals, citizens of foreign countries, up to and including the age of
70, in whose favor the contract has been concluded.
3.Under the Contract, the costs of medical and other services provided to the Policyholder
(Insured Person) during the trip to Ukraine upon the occurrence of events provided for in
this Contract shall be reimbursed.
4.The insured event is the actual provision of medical and other services to the Policyholder
(Insured Person) on the territory of Ukraine, provided for in clause 2 of the Contract, as a
result of a sudden illness or accident threatening the life and/or health of the Insured
(Insured Person).
2. Insured events
1. Services provided by the Insurance Program:
1.Urgent outpatient treatment at the pre-hospital stage and/or in an outpatient setting, in
the day patient department of a medical institution (doctor's visit, examination and
consultation, urgent diagnostic tests, outpatient surgery, therapeutic treatment, purchase
of medication) urgent hospitalization — urgent research, therapeutic treatment in a
hospital, medical personnel services;
2.Hotel services (cost of staying in a standard-type ward, intensive care ward, emergency
treatment room, medical care prescribed by a doctor, purchase of medication), including
covering the costs of isolation of the Insured and persons who were in close contact with
the Insured;
3. Purchase of medicines prescribed by a doctor for emergency care;
4.Diagnosis for COVID-19 of persons who were in close contact with the Insured person in
case of detection of COVID-19 infection of the Insured person.
5.Emergency dental care — dental services provided to the Policyholder (Insured person)
for medical reasons within the established limits of liability: in case of acute toothache that
requires the provision of emergency dental care — the equivalent of 150 Euro.
6.Emergency obstetric care provided to the Policyholder (Insured person) for medical
reasons in case of a threat to the life and health of the Policyholder (Insured person),
provided that the period of pregnancy of the Policyholder (Insured person) was up to 29
(twenty nine) weeks
INSURANCE CONTRACT FOR P E R S O N S TRAVELING UKRAINE
( M e d i c a l e x p e n s e s ins urance)
Kyiv 27.07.2021
This Offer is an o昀 케cial proposal of the Additional Liability Company " Euroins Ukraine IC "
(hereinafter referred to as the Insurer), addressed to legally competent individuals, to enter
into a Voluntary Health Insurance Contract (continuous health insurance), (accession).
This Contract of voluntary medical expenses insurance, hereinafter — the
Contract/Insurance Contract, is concluded in accordance with the license of the National
Commission for State Regulation of Financial Services Markets for the right to insure
medical expenses issued on the basis of Order No. 2696 dd. 25.10.2016 and the Rules of
voluntary insurance of medical expenses of illness, registered by the State Commission for
Regulation of Financial Services Markets of Ukraine on 26.01.2007 (hereinafter - the
“Rules”)
This Insurance Contract consists of two parts of the Insurance Policy and the Offer (Annex
№1).
I n s u r a n c e policy № 0 2 0 4 3 8 С1 9 -0 0 2 о т 27.07.2021
1. I nsurer PJSC “Euro ins Uk ra ine IC”, EDRPOU code 22868348, Certi昀 椀cate of registration of a 昀
椀nancial
institution series СТ No. 236 dd. 21.08.2004, registration number 11100923, issued on the basis of the
decision of the Financial Services Commission No. 1224 dd. 24.06.2004 , current account
UA033802690000026501056200817 in JSC CB “PRIVATBANK”, represented by the Chairman of the
Management Board Nikolov Yanko Georgiev and the Deputy Chairman of the Management Board
Yakovenko Andrii Valeriiovych acting on the basis of the Charter location: 03150, Kyiv, 102, Velyka
Vasylkivska Street, tel. + 3 8 044 247 44 77, e-mail address
2. Policyholder Full name ALQAHTANI ABDULLAH Phone number +966554222524
Address Saudi Arabia ( ةيبرعال ةكلممال Date of birth 09.02.1998
)ةيدوعسال
3. B e n e 昀
椀ciary Unaasined
4. Pl a ce of the Ukraine
C o ntra ct validity
5. Validity fro [29.07.2021] to [08.08.2021]
m
The Insurance Contract comes into force from the moment indicated as the Contract commencement date, but not earlier than 00
hours 00 minutes of the day following the day of receipt of the insurance premium in full to the account of the Insurer, or
following the day of paying the insurance premium through other payment systems that are allowed by the legislation of Ukraine
and which are introduced by the Insurer.
6. S u m insured E U R 30,000 E U R per insured p e r s o n
7. I n s u r a nc e rate 0.50052%
8. I n s u r a nc e 500.52грн.
premium
9. E v e n t s insured :
Voluntary insurance of The insured event is the fact that the Policyholder (Insured Person) receives medical services, namely
medical expenses the provision of ambulance and/or urgent (emergency) inpatient medical care, provision of
diagnostics and medication, the need for which arose as a result of an acute illness, including as a
result of the coronavirus infection C OVI D-2019.
10.Persons insured:
Full n a m e D a t e of birth Passport Phone number
ALQAHTANI ABDULLAH 09.02.1998 Y887514 +966554222524
, lOMoARcPSD|16248954
11.Total sum insured: [100000* number of insured]
13. Total insura nce p r e m i u m 30,000 EUR
14. S i g n a t u r e of the I n s u r ed 500.52 грн.
Upon the occurrence of an insured event, you must immediately contact the assisting
company Euroins Ukraine by calling tel. 0 8 0 0 5 0 1 0 0 1
Annex №1 to the Insurance Contract for Persons Traveling to Ukraine
1. The subject of th e contract
1.The subject of the Contract is property interests that do not contradict the Law and are
related to the life, health and ability to work of the Insured (Insured Persons).
2.Insured persons — individuals, citizens of foreign countries, up to and including the age of
70, in whose favor the contract has been concluded.
3.Under the Contract, the costs of medical and other services provided to the Policyholder
(Insured Person) during the trip to Ukraine upon the occurrence of events provided for in
this Contract shall be reimbursed.
4.The insured event is the actual provision of medical and other services to the Policyholder
(Insured Person) on the territory of Ukraine, provided for in clause 2 of the Contract, as a
result of a sudden illness or accident threatening the life and/or health of the Insured
(Insured Person).
2. Insured events
1. Services provided by the Insurance Program:
1.Urgent outpatient treatment at the pre-hospital stage and/or in an outpatient setting, in
the day patient department of a medical institution (doctor's visit, examination and
consultation, urgent diagnostic tests, outpatient surgery, therapeutic treatment, purchase
of medication) urgent hospitalization — urgent research, therapeutic treatment in a
hospital, medical personnel services;
2.Hotel services (cost of staying in a standard-type ward, intensive care ward, emergency
treatment room, medical care prescribed by a doctor, purchase of medication), including
covering the costs of isolation of the Insured and persons who were in close contact with
the Insured;
3. Purchase of medicines prescribed by a doctor for emergency care;
4.Diagnosis for COVID-19 of persons who were in close contact with the Insured person in
case of detection of COVID-19 infection of the Insured person.
5.Emergency dental care — dental services provided to the Policyholder (Insured person)
for medical reasons within the established limits of liability: in case of acute toothache that
requires the provision of emergency dental care — the equivalent of 150 Euro.
6.Emergency obstetric care provided to the Policyholder (Insured person) for medical
reasons in case of a threat to the life and health of the Policyholder (Insured person),
provided that the period of pregnancy of the Policyholder (Insured person) was up to 29
(twenty nine) weeks
