INTERNATIONAL EMERGENCY MEDICAL SERVICE

SCHENGEN CERTIFICATE

Beneficiary Information:

First and Last Name of Beneficiary: Gabriel Repulblicano

Number of Visa Card or Visa Account (first six digits): 422061XX XXXX XXXX

Type of Visa Card or Visa Account: Visa Platinum

Trip starting date: 4/16/2016 Trip ending date: 6/1/2016

The maximum coverage for the International Emergency Medical Service is 150,000 USD and includes some of the following
benefits:

Medical Expenses in case of accident or sudden illness of cardholder, spouse of

dependent children
Emergency Medical Evacuation
Repatriation of remains

This service fulfills the provisions that the European Union requires to grant Schengen visas.
For your convenience these benefits may be paid directly to the provider.
These benefits are in accordance to the terms and conditions applied to this service. Please refer to your benefits guide provided by
your bank.

The International Emergency Medical Service is offered exclusively to Visa cardholders for eligible international trip. An International
trip is eligible under these circumstances:

The trip is outside of the beneficiary’s country of residence and country of card issuance
The benefits provided are only valid for an eligible trip for up to sixty (60) consecutive days from the departure date of country of
residence or country of card issuance of such eligible trip.
Full amount of the international tickets, taxes and fees related were paid to a transportation company an eligible Visa Card or Visa
Account.
The international tickets were purchased by redeeming points from a bank loyalty program , provided that the boarding fee and possible
taxes due have been paid with an eligible Visa card or Visa Account. If no boarding fee or taxes are levied, the tickets were purchased by
redeeming points obtained through utilization of a valid Visa rewards program.
Expenses related to any pre-existing conditions are excluded.

While traveling please keep the following recommendations in mind:

In the event that an emergency occurs, It is required that you contact the VISA Assistance Center immediately or within 30 days
following the date on which the MEDICAL EMERGENCY or ACCIDENT occurred.
Please refer to your benefits guide provided by your bank. The final determination of service is subject to the terms,
conditions and exclusions of AXA Assistance USA We encourage you to review the benefits guide for further details.

The VISA Assistance Center is available 24 hours a day, 7 days a week at the following telephone numbers:
+1 (800) 396 9665 from North America, Puerto Rico, and US Virgin Islands.
(303) 967 1098 Collect call from any country outside of the United States

Visa ASSISTANCE CENTER

Email: visa_iemstravel@axa-assistance.us
Fax: +1 (312) 896-5569