DECLARATION OF MEDICAL INSURANCE
PPLIB2STONTT Certificate Types ro
Pariot Platinum InteratonsliSM) Prema: 7.37 USD.
O2Aug2019 ‘Adventure Sports: Ne
25-Aug-2019
380.0080.
$.000.00000 USD
applemcntal Accidental Death: 040 USD
arenas ll at all ns be subject We fal ern condition detninons and exclusions contained the cova
Person(s) Tnvured 1D Date of Birth
(O10, BEDAA, AS14009 25.808 98S
jsidence Addrenss SUIT STREET —lobannesbarg — 200] -SOUTHAFRICA
cred By: INTERNATIONAL MEDICAL GROUP, INC. as apeat for Ue Tasarer
er ‘SlrbesLnternatlonal Inverance Corporation (publ)
‘witness whereof this certificate been sgpod, as authorized by the inser by
‘lest review thi information for accurey. Ifyou fin any discrepancies, please coat! Intestinal Medica! Group a5 sora possible, Please
reference your cerficate umber aot below when comacting IMIG at se
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