CERTIFICATE OF INSURANCE - GOUDA STUDENT INSURANCE
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1 CERTIFICATE OF INSURANCE - GOUDA STUDENT INSURANCE Policy no: Insured: Date of issue: Valid for twelve (12) months from Expiration date: Geographic region: Worldwide Country of studies: USA SUMMARY OF COVER - GOUDA STUDENT INSURANCE INSURANCE COVERAGE MAXIMUM COVERAGE (NOK) OWN RISK (NOK) Luggage Robbery or theft of money Tickets, passport PC Cell phone Medical treatment Dental treatment acute illness Dental treatment accident Loss of school fees due to medical emergency Accident Disability Death Repatriation (Medical evacuation ) Unlimited Unlimited Summoning Interrupted stay (call home) Unlimited/ Home insurance Personal liability Legal assistance Evacuation Cancellation of journey due to medical reasons Included in Gouda Student Insurance is a 45 day maximum World Wide travelers insurance. The above is just a summary of the most important coverage of the Gouda Student Insurance. A complete account of coverage and limitations can be found in the full policy conditions. The insurance contract is issued accordingly to The Insurance Contracts Act (FAL) of 16 June The insurance contract consists of the following documents: - Coverage note, invoice and safety precaution regulations. - Attached insurance conditions and terms The insurer is Gouda Travel Insurance, Rådhusgaten 17, 0158 Oslo, rway (org. number ), Branch of Goudse Schadeverzekering, N. V, Gouda, The Netherlands. GOUDA ALARM TELEPHONE NUMBER:
2 HENVENDELSER VED ULYKKER, SKADER OG TAP - GOUDA REISEFORSIKRING WHERE TO REPORT ACCIDENTS, INJURIES AND LOSSES GOUDA TRAVEL INSURANCE Gouda Studentforsikring sikrer deg assistanse og legehjelp 24 timer i døgnet, uansett hvor i verden du befinner deg. Det er Gouda Alarmsentral som koordinerer disse tiltakene. Gouda Student insurance ensures you emergency assistance 24 hours a day, regardless where in the world you are situated. Gouda Emergency Center will coordinate the work. Nedenfor finner du en oversikt over telefonnummer, e-post og web-adresser for hjelp og skadebehandling. Under, please find the telephone numbers, and web addresses for assistance and other claims. Ved akutte ulykker og skader / In case of a serious accident or acute illness, please contact: Gouda Alarm / Gouda Emergency Center, Denmark Phone: Fax: alarm@gouda.dk Emergency in USA, you may also use tel (Will be directed to Gouda Emergency Center) For mindre skader eller spørsmål om andre tap / For injuries which are not acute or other claims, please contact: Gouda Reiseforsikring / Gouda Travel Insurance, rway Rådhusgaten 17, 0158 Oslo Phone: Fax: Internett post@gouda.no
3 Claims form Travel Insurance Illness and other claims not related to luggage Please fill out all fields and enclose original documentation. Processing your claim cannot begin before we have received all relevant. Please fill out all fields in the claims form, otherwise the claims handling will be prolonged. 1. Personal Name: Address: Postal code.: Town: Social security.: Phone (work): Phone (private): Police.: 2. Bank Please transfer the compensation to (please tick off): Bank name: In case of transfer to foreign bank Iban no./account no.: Bank account Account no.: Swift/Bic code: 3. Other insurance Insurance company: Policy.: Has the claim been reported to other insurance company? If yes, please state date? Which credit cards do you have? (please tick off) Mastercard Diners Amex EuroCard Did you pay more than 50% of the voyage with the What bank has issued the card? Type of card? (tick off): Gold Platin Card no. Private creditcard Company creditcard Other? 4. Coverage For what are you claiming compensation Illness Cancellation (tick off)? Repatriation Medical escort Missed departure Private liability /legal aid Accident/assault Delayed flight Replacement person Loss of vaccation days Personal safety Summoning Other 5. The incident When did the incident occur (day/month/year)? In what country did the incident occur? Please describe the incident in details (if necessary please attach separate description):
4 6. Travel Purpose of the journey? (please tick off) Departure (day/month/year): Business Holiday/business Holiday Arrival (day/month/year): Travel agency/tour operator: 7. Illness/accident/ injury Date and time for the illness/accident/injury When were you reported fit for work? Date and time for 1.st consultation: Hospitalisation (date from/to): From: To: Have you previously suffered from the same illness/experienced the same symptoms? If yes, when? Name/address/phone number to your general practitioner: Diagnosis/nature of the illness/accident: Where you repatriated by Gouda Alarm Centre? If yes, when (day/month/year): 8. Expenses Expences (physician, medicine, transport, food, accomodation etc.) Expences (local currency) Expences (NOK) Have you already paid? (yes/no) IMPORTANT: Please enclose original documentation Total: 9. Signature I hereby give Gouda Travel Insurance my consent to obtain all relevant, regarding my claim, herein: - Medical and social, including from my contact with the health authorities. - Information from general practitioners, hospitals and other relevant parts of the health authorities, public services, including municipal and Occupational Board and from other insurance companies, pension funds and the police. This consent includes health-related up until the time Gouda Travel Insurance has reviewed my claim. A copy of the consent may be given to the above mentioned, who are requested to provide to Gouda Travel Insurance. Date: Signature: Gouda Travel Insurance Rådhusgaten Oslo. rway Tlf skade@gouda.no Org.no Branch of Goudse Schadeverzekeringen N.V. Gouda Holland Reg.no
5 Claims form Travel Insurance Luggage (theft/delay/loss/damage) Please fill out all fields and enclose original documentation. Processing your claim cannot begin before we have received all relevant. Please fill out all fields in the claims form, otherwise the claims handling can be prolonged. 1. Personal Name: Social security.: 1. Personal Address: Postal code.: Phone (work): Phone (private): Police.: 2. Bank Please transfer the compensation to (please tick off): Bank name: Bank account Account no.: 2. Bank In case of transfer to foreign bank Swift/Bic code: Iban no./account no.: 3. Other insurance Insurance company: Policy.: Has the claim been reported to other insurance company? If yes, please state date? Which credit cards do you have? (please tick off) Mastercard Diners Amex EuroCard Did you pay more than 50% of the voyage with the What bank has issued the card? Type of card? (tick off): Gold Platin Card no. Private creditcard Company creditcard Other? 4. Travel Purpose of the journey? (please tick off) Departure (day/month/year): Business Holiday/Business Holiday Arrival (day/month/year): Travel agency/tour operator: Where did the loss occur (country)? 5. Luggage delay When did the delay occur (day/month/year)? Enclose original PIR (personal irregularity report), receipts, printed ticket, boarding card and baggage tag Has the delay been reported to the transport company? (flight/bus/train/ferry) original documentation must be attached When was the luggage delivered (day/month/year)? If no, please note why this has not been done: Time of delivery?
6 6. Damage/theft When did you notice the incident (day/month/year)? When did the incident occur if different (day/month/year)? Please describe the incident in details (if necessary please attach separate description): Who was the incident reported to (tick off)? Police Hotel Guide Original documentation must be attached: Gouda alarm centre Gouda Transport company Other? (original documentation must be attached): Where were the items Carried Car Train Plane at the time of the incident? (tick off). Hotel Bus House/apartement Elsewhere Was the luggage checked in/deposited? If yes, with whom? Was the storage area locked? Were there any signs of forced entry? If yes, what were the signs? 7. Lost objects / delayed luggage What have you lost/bought? Date of purchase Purchase price Claim (local currency Claim (NOK) Enclose original documentation Total 8. Signature I hereby give my approval that Gouda Travel Insurance can collect all relevant from transport company, police and other relevant authorities. Date: Signature: Gouda Travel Insurance Rådhusgaten Oslo. rway Tlf skade@gouda.no Org.no Branch of Goudse Schadeverzekeringen N.V. Gouda Holland Reg.no
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