Travel Certificate

Beneficiary: 1 Issue Date: 11/11/2023 No. 1374466-000

Family Name: . Date of Birth: 03/04/1992
First Name: AMITH GOASH Gender: M
Middle Name: . Passport No: A07555039
Country of Residence: Bangladesh Nationality:
Address:
Tel: 77988653 Email: amitopen007@gmail.com
Coverage
Plan: Covid-19
Coverage Zone: Schengen, GCC & MENA Region
Destination: Belgium Sports Activities: Not included
Period of Coverage: 7 Days Inception: 28/12/2023 Expiry: 03/01/2024

Benefits per beneficiary

Emergency medical evacuation, up to $1,000,000
Emergency medical repatriation, up to $1,000,000
Transportation of mortal remains, up to $1,000,000
Medical expenses incurred during hospitalization, up to $55,000
Medical expenses incurred during hospitalization due to Covid19, up to $35,000
Compassionate visit, up to $5,000
Medical expenses incurred during hospitalization, for ages 80 till 89(including Covid-19) up to $20,000
Quarantine Ecpenses per day (up to 10 days) $50
Dental emergency due to accident, up to $500
Loss of Passport $400
Loss of Documents, up to $250
Luggage Loss per Kg up to 40Kg $20
Trip Cancellation, up to $750
Maximum stay per trip 92 days
Luggage Delay $500
Trip Curtailment $1,000
Medical & Travel Assistance Free Service
Deductible up to 80 years $0
Deductible from age 80 till 89 $1,374

Deductible: As per policy/certificate general conditions

*By receiving this certificate you declare to agree to the terms, exclusions and limitations of the Travel Insurance program General conditions. Please
read the certificate carefully, the general conditions (https://www.safetriponline.com\GeneralConditions\QCV - GC- 19.06.2023.pdf) and any other
documents provided. Signature

5505-QIIC-Int. integration
http://www.isatravelonline.com/validate/