www.adac.

de

Thank you for your trust and your application for

ADAC health protection abroad!

We have received your application and will review it immediately. We will then notify
you and send your insurance documents. The insurance certificate is only valid if the
amount could be debited from your account on time.

Your details on the ADAC foreign health protection insurance

Insurance
Customer number none specified

Start of insurance 04/26/2022

Immediate protection: No,

Contract/tariff Individual contract / EXCLUSIVE

Costs per year €86.20

Personal data

Salutation Woman

first name Bela

Surname Iashvili

Street, No. Bernhard-Göring-Strasse 156

ZIP code, city 04277 Leipzig

Date of birth 12/21/1935

E-mail skobulia@yahoo.com

Direct debit

IBAN BExxxxxxxxxxxxxxxxxxxx03012

BIC TRWIBEB1XXX

Different Kto. owner Yes,

Salutation Mr.

first name Aleksandre

Surname Kobulia

Address addition (optional)

Street, No. Bernhard-Göring-Strasse 156

ZIP code, city 04277 Leipzig

 Consent

I have taken note of the contents of the following documents and acknowledge them

Consumer information Foreign health insurance Exclusive, 170.78 KB

Information sheet Foreign Health Insurance Exclusive, 280.94 KB

Cancellation policy, 29.16 KB

The download or printout was successful.

With the online conclusion, I waive a telephone or personal consultation.

Important: Only personal advice guarantees needs-based insurance coverage. A waiver
can negatively affect any claims for damages (§6 para. 5 VVG).

ADAC Insurance Corporation

Hansastraße 19 · 80686 Munich
Board of Directors: Claudia Tuchscherer (Chairman), Stefan Daehne, James Wallner
Chairman of the Supervisory Board: Mahbod Asgari Nejad
Legal form: Public limited company based in Munich
Registered at the Munich District Court, HRB 45842

Online dispute resolution platform of the EU Commission

The online dispute resolution platform ("OS platform") for the out-of-court settlement of
disputes arising from contracts concluded online can be reached at the following link:
https://ec.europa.eu/consumers/odr/

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