rystal Studies Insurance solutions for international students STUDIES HOLIDAYS INTERNSHIPS AU PAIR PLACEMENTS international

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1 [ LA MOBILITÉ] INDIVIDUALS rystal Studies Insurance solutions for international students STUDIES HOLIDAYS INTERNSHIPS AU PAIR PLACEMENTS APRIL International supports the Foundation for Nature and Mankind and Handicap International Follow us on Facebook and Twitter international Changing the face of insurance.

2 [CRYSTAL STUDIES] Crystal Studies, comprehensive insurance for studying abroad! Crystal Studies is an insurance solution designed for students and schoolchildren living abroad for up to a year for the purposes of travel, language training, au pair placements, internships or studies. Why take out international insurance? The cost of healthcare abroad varies greatly from one country to another and can be very expensive. Often, the insurance cover you are entitled to at home is not valid abroad so, if you have health problems and need treatment, you have to pay the costs yourself. Faced with medical expenses? Emergency hospitalisation? Doctor s appointment? Crystal Studies covers you for both regular and unexpected medical expenses from the 1st euro you spend. There is no excess to pay and we can arrange for your hospital bills to be settled directly. This means you have nothing to pay to the hospital. We'll take care of it! Need assistance during your trip? Involved in an accident and need to be repatriated straight away? Hospitalised and awaiting the arrival of a relative? APRIL International will organise your repatriation, at any time, day or night, to your home or to the most suitable hospital. We also cover the transport and accommodation costs of a relative coming to stay with you. Responsible for damage to others? If you damage the equipment you're using during your internship? APRIL International covers you for damage caused to a third party in a private capacity or during your internship. Your benefits with Crystal Studies FROM 25 No waiting period or excess on medical expenses No cash advance if you are hospitalised Reimbursement of your medical expenses within 48 hours Cover valid in each country you visit and during short return trips to your country of nationality Meets requirements for the biggest international universities and the Schengen visa authorities A translation service and a legal assistance hotline to help you with administrative procedures PER MONTH Our multilingual teams at your service: by telephone: +33 (0) Monday to Thursday from 8.30 to (8.30 to on Friday) - Paris time by info@aprilmobilite.com at our offices: 110, avenue de la République - CS Paris Cedex 11 - FRANCE 2

3 Take a look at our healthcare benefits specially designed for trips to the USA NEW! and our special healthcare benefits in France In association with our partners, APRIL International has created exclusive services: access to one of the largest healthcare networks in the United States with nearly 450,000 doctors and more than 4,500 hospitals ; using this network means you have no cash advance to make and we'll settle your bill for you a third-party pharmacy payment card: no cash advance required for pharmacy expenses in the United States A third-party payment card accepted by over 100,000 healthcare professional partners. With this card you no longer need to make a cash advance for the following expenses: medicines in pharmacies visits to general practitioners a home consultation service: no long waits in the emergency room and no need to pay for the consultation diagnostic tests X-rays 3

4 [CRYSTAL STUDIES] Benefits For periods of 1, 2, 3 6 or 12 months, get insurance cover designed specially for international students. 1 - MEDICAL EXPENSES Up to 200,000 per insurance year HOSPITALISATION Medical or surgical hospitalisation: Transfer by ambulance (if hospitalisation is covered by APRIL International) Accomodation (including daily hospital charge in France) Medical and surgical fees Examinations, tests and medicines Medical procedures Hospitalisation for the treatment of mental or nervous disorders Direct payment of hospital charges during approved hospitalisation for more than 24 hours 100% of actual costs 80% of actual costs, up to 20 days per year provided on request 24 hours a day, if prior agreement has been obtained (unless a cover as a top up to the EHIC has been selected) Private room Examinations and treatment carried out in hospital and lasting less than 24 hours up to 50 a day 100% of actual costs ROUTINE HEALTHCARE Consultations, visits and procedures carried out by GPs or specialists Diagnostic tests, laboratory tests, x rays and drugs Procedures carried out by medical auxiliaries (following a reported accident) Emergency dental treatment Cost of dentures (following a reported accident) Prostheses excluding dentures (following a reported accident) Eye care: lenses, contact lenses and frames (following a reported accident) 100% of actual costs (limited to 130/year for eye care consultations and to 80% of actual costs and 5 sessions/year for the treatment of mental or nervous disorders) 100% of actual costs 100% of actual costs up to 400 per year up to 600 per year up to 500 per year Contraceptives (condoms) up to 20 per year DEFINITIONS Actual costs: total medical expenses charged to you. Daily hospital charge: portion of daily hospital costs in France not covered by French Social security. Reported accident: an accident recorded by a competent authority present at the scene (police, firefighters or paramedics) where a certificate was issued specifying the circumstances of the incident, the nature of the injury and the date of the accident. Direct payment of hospital charges: if you are hospitalised for more than 24 hours, we can pay your hospital charges on your behalf: we will contact the hospital to settle your bill and you have nothing to pay up front. 4

5 APRIL REIMBURSES YOU WITHIN 48 HOURS NO UPFRONT PAYMENT IF YOU ARE HOSPITALISED How to claim reimbursement of your medical expenses 1 If you opted a cover from the 1 st euro spent See a healthcare professional > Send your medical bills to APRIL International > Your reimbursement is processed within 48 hours (excluding postal delivery and bank processing times) > international 2 If you opted for a cover as a top-up to the EHIC > > > > > Your reimbursement is based on the Social Security rates in your host country + See a healthcare professional Send your medical bills to Social Security in either your host or home country OR Your reimbursement is based on the Social Security rates in your home country You then send your Social Security statement to APRIL International international Your top-up reimbursement is processed within 48 hours (excluding postal delivery and bank processing times). SOME USEFUL TIPS BEFORE YOU LEAVE: Ë Scan or photocopy all your important documents: visa(s), identity papers (passport,...), as well as your airline tickets or international driving licence; this will make it easier to make a claim if they are lost or stolen, Ë Check the expiry date on your credit or debit card, if you are taking it with you, Ë Keep receipts or invoices for your valuables (camera, laptop etc.). This will be helpful if you need to make a baggage claim, Ë Don t forget your insurance card or APRIL International client reference number so that you can reach us quickly if problems arise. THE EUROPEAN HEALTH INSURANCE CARD (EHIC) The European Health Insurance Card provides proof of entitlement to healthcare insurance for members of the European Union. It allows you to access the public healthcare system while on a temporary stay in another Member State in accordance with local legislation and formalities. It is valid for 12 months. The card can be used in the following countries: Austria, Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Finland, France (including Guadeloupe, Martinique, French Guyana and Reunion Island), Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Lichtenstein, Lithuania, Luxemburg, Malta, the Netherlands, Norway, Poland, Portugal (including Madeira and the Azores), Romania, Slovakia, Slovenia, Spain (including the Balearic and Canary Islands), Sweden, Switzerland and the United Kingdom (including England, Scotland, Wales, Northern Ireland and Gibraltar). 5

6 [CRYSTAL STUDIES] Benefits (continuation) For periods of 1, 2, 3 6 or 12 months, get insurance cover designed specially for international students. 2 - REPATRIATION ASSISTANCE Medical evacuation and repatriation Presence of a family member for hospitalisation of more than 6 days covered return ticket and 80 per night, maximum 10 nights Early return home in case of death or hospitalisation of a family member Early return home due to a terrorist attack or natural disaster Procurement and shipment of medication not available locally covered reimbursement of your travel costs covered Search and rescue costs up to 5,000 Return of remains costs covered Provision of coffin up to 1,000 Advance payment of bail abroad up to 15,000 Passing on urgent messages Travel assistance if personal items are lost or stolen covered up to 1,000 (advance) Enforced stay abroad Translation of legal and administrative documents 3 - LEGAL ASSISTANCE Legal information and safety advice by phone 4- COUNSELLING Exchanges with a clinical psychologist 80 per night, maximum 5 nights (accommodation and food) up to 500 per year covered telephone calls or exchanges of 5 - PERSONAL LIABILITY private capacity, interships and tenant's liability Bodily injury up to 4,500,000 Material and consequential damage to a third party up to 460,000, including 92,000 for consequential damage, excess 75 Material damage caused to manager during internships up to 12,000, excess 75 Legal cover - recourse up to 3,100, for costs over PERSONAL ACCIDENT Accidental death 10,000, or funeral expenses for the under 16 s Accidental disability up to 40,000, proportional excess 20% 7- BAGGAGE COVER Luggage which is lost, stolen or destroyed in an explosion or fire or by water during the outward or return trip or during the stay 8- DELAYED DEPARTURE Reimbursement of fees charged by airline company for change of outward flight up to 1,600, excess of 15 per claim, benefit limited to 50% for valuables, i.e. up to 800 up to 100, airline tickets only 6

7 EXCLUSIVE! ENFORCED STAY ABROAD If a "force majeure" event prevents you returning to your home country as planned, we will cover your additional accommodation costs and extend your policy until you get home. How can we help you? At the end of your study year in Canada, you decide to take some time out to explore the Rocky Mountains. As you make the final descent, you slip on damp ground, break your leg and suffer extensive bruising. Ë With Crystal Studies, you will be flown by emergency helicopter to the nearest hospital and, if you need to stay longer in hospital, we will arrange for a family member to be with you. You ve just arrived in France for an exchange year and are a bit lost with all the paperwork waiting for you. Ë You call the APRIL International legal and administrative hotline; our consultants will tell you all you need to know about opening a bank account in France, getting a work permit, understanding the rental agreement for your apartment and assisting you with your visa application etc. You re going to work as an au pair in France. Everything goes perfectly to plan, you are warmly welcomed by the family and the two children are making good progress thanks to your English lessons. At the end of your third week, you trip and accidentally knock over a very old and very expensive piece of sculpture. Ë With your personal liability cover, your host family will receive compensation to replace the sculpture and you can continue your stay under the best possible conditions! On an internship in Brazil you lose your backpack during a visit to Rio. Everything is gone: your laptop, camera and, most importantly, your passport and wallet. Ë APRIL International will advise on how to get your documents replaced and offer you a cash advance until you get a new bank card. You will also receive compensation for your stolen belongings. 7

8 [CRYSTAL STUDIES] Examples of reimbursements With Crystal Studies international cover, you're protected from anything that might threaten to disrupt your time abroad. While I was in the States, I was rushed into hospital with appendicitis. Cost of 2 days' hospitalisation: $15,200. APRIL International settled my bill directly with the hospital and I had nothing to pay. I am insured under a Crystal Studies 1 st euro policy. US$ APRIL International reimbursement US$ 0 You pay Paola, Spanish au pair in Atlanta, USA I saw a specialist for an ear, nose and throat infection. Cost of the consultation: 60. I am insured under a Crystal Studies EHIC top-up policy. Paul, French exchange student in Rome, Italy Social security reimbursement APRIL International reimbursement 0 You pay I saw a GP for back pain. Cost of the consultation: 40. I am insured under a Crystal Studies 1 st euro policy. Juan, Brazilian student in Lyon, France By simply showing my third-party payment card to my doctor, I had nothing to pay. 8

9 Monthly premiums (all taxes included) For policies taken out before 01/10/2012. A fee of 3 per month will apply if you are paying in monthly instalments and will be added to your premium. Payment in monthly instalments is not available if your stay includes a half month. Level of cover Type of cover Length Age band Complete option: Benefits 1 to 8 Mini option: Benefits 1 and 2 only Cover from the 1 st euro spent Cover as a top-up to the EHIC Cover from the 1 st euro spent Cover as a top-up to the EHIC 15 days month days month days month days month EHIC top-up cover is available to children and students who are covered by the statutory Social Security scheme of one of the EU countries. To qualify, you must apply for a European Health Insurance Card from your Social Security centre before leaving. You should then show the card to the medical authorities in your host country. In this case, APRIL International will only provide top-up reimbursements if you can provide evidence of having received medical care under the statutory scheme. Unlike the Complete option, the Mini option does not provide cover for all eventualities arising during a trip abroad. It provides basic cover but APRIL International recommends the Complete option. SPECIALLY DESIGNED FOR YOUNG PEOPLE ABROAD, EXCLUSIVE BENEFITS! Having trouble understanding a document in a foreign language? A tenancy agreement in German, an employment contract in English or a certificate from your host university in Chinese? Simply ask us for a translation of the administrative or legal documents you need. Questions about visas, work permits? How to open a bank account abroad? Our multilingual hotline is available to answer all your practical and legal questions, Monday to Saturday from 9 am to 8 pm. Your washing machine leaks and causes water damage to the apartment below yours? With your tenant's liability cover, we will pay for any damage to your neighbour's apartment. You cause damage to property during your end-of-studies internship? With the extension of your liability cover to internships, you're covered if you cause damage to equipment used during your internship. 9

10 [CRYSTAL STUDIES] How the policy operates Useful information before you apply WHO IS THE POLICY DESIGNED FOR? - any student, school pupil or au pair under the age of 41, living abroad, - for the purposes of travel, language courses, au pair placements, internships or studies. WHERE AM I COVERED? You are covered anywhere in the world (including in your country of nationality during short return visits). If you selected an EHIC top-up policy, you are covered in all EU countries as well as Switzerland, Norway, Iceland and Liechtenstein (and during short visits to your country of nationality). Certain countries may be excluded from the policy as a result of heightened tension there. The list of excluded countries is available on request by calling +33 (0) WHAT IS THE MAXIMUM PERIOD OF COVER? The Crystal Studies policy is available for a minimum period of one month and a maximum of 12 months. It is renewable with the insurers' agreement on condition that you remain in full-time education or that your au pair placement continues. HOW TO APPLY Fill in and sign the attached Application form Enclose a photocopy of your student card or school attendance certificate (if you are going abroad to work as an au pair, please enclose a copy of your contract with the host family along with your application form) If you are paying in full: - enclose a cheque in payable to APRIL International Expat or - provide your credit/debit card details on the Application form If you are paying in monthly instalments from your French bank account: - fill in the attached direct debit authorisation form - enclose details of your bank account Send your application to: APRIL International Expat - Service Adhésions Individuelles - 110, avenue de la République CS Paris Cedex 11 - FRANCE WHAT HAPPENS IF I CHANGE OR CANCEL MY TRIP? If you cancel your trip, we will refund your premium if you let us know in writing before the effective date of your policy and you return the original of your Membership certificate and your APRIL International card, if you have one. If you decide to cut short your stay and return permanently to your country of nationality, you should send us a registered letter with proof of receipt enclosing documented evidence of your return home (receipt for payment of electricity, gas or telephone bill, etc). We will then cancel your policy and refund any premium due. 10

11 Services to support you throughout your stay abroad ONLINE YOUR PERSONAL SPACE If you are insured, you can view: your reimbursement advice notes, details of cover and the general conditions that apply, your personal and bank details. If you are the member, you can: view your personal details and those of your insurance consultant, check your premium payments and payment method, pay your premiums online using a bank card. EXTENSIVE THIRD PARTY PAYMENT SERVICES GOING TO THE UNITED STATES? STAYING IN FRANCE FOR MORE THAN 6 MONTHS? Take advantage of exclusive services specially designed to simplify procedures while respecting your budget! For all your routine healthcare costs (pharmacy, consultations, diagnostic tests and x-rays) with partner medical service providers, you have nothing to pay; we'll settle your bill for you! DIRECT PAYMENT OF YOUR HOSPITAL CHARGES If you are hospitalised for more than 24 hours, we can pay your hospital charges on your behalf: we will contact the hospital to settle your bill and you have nothing to pay up front. This service is subject to medical approval. (unless you selected EHIC top-up cover) Crystal Studies Mr MARINI Christophe N de contrat / Policy number: Date de couverture / Period of cover: 01/10/ /05/2012 The above person benefits from the direct payment of hospital fees. Kindly facilitate hospital admission calling one of the numbers noted on the other side of this card. Information Tél : +33 (0) international YOUR INSURANCE CARD INCLUDING EMERGENCY CONTACT NUMBERS, AVAILABLE 24/7 FOR: direct payment of hospital charges if you are hospitalised for more than 24 hours (unless you selected EHIC top-up cover), requesting emergency assistance, contacting the counselling service. The card facilitates your admission to a medical centre in the event of emergency hospitalisation, for more than 24 hours. To simplify procedures, the card contains your personal details: name, first name(s) and policy number. APRIL INTERNATIONAL CARES As part of our commitment to protecting the environment and improving the living conditions of disadvantaged populations worldwide, APRIL International is proud to support the Foundation for Nature and Mankind and Handicap International. You can contribute to one of these associations by donating: - an additional 5, 8 or 12 when paying your premium or, - the cents from your healthcare reimbursements. 11

12 APRIL, changing the face of insurance From our beginnings in 1988, APRIL has been committed to changing the face of the insurance industry by ensuring that the client is always at the heart of our business. Today, more than 3 million people know they can count on our 3,750 employees and 50 companies to protect their goods and families day after day. WORLDWIDE PRESENCE IN 34 COUNTRIES APRIL has earned that trust by providing insurance products that combine a fair price with a reassuring level of cover and quality service; proof indeed that insurance is not what it used to be. APRIL International, specialising in international insurance for more than 35 years Our promise: Top quality management of your insurance choices: applications processed within 24 hours and reimbursement of medical expenses within 48 hours Multilingual teams at your service Clear and easy to understand products supported by a range of services For every expatriate situation, an international insurance solution Whether you're a student, on an internship, planning a working holiday, in work or retired, travelling alone or with your family, APRIL International will support you during your time abroad with a range of comprehensive and flexible insurance solutions suitable for all kinds of expatriates and all budgets. FOR MORE INFORMATION, CONTACT YOUR INSURANCE CONSULTANT All the APRIL International Expat trademarks, logos, graphics and commercial material contained in this document are registered and are the property of APRIL International Expat. Any reproduction of any kind, either partial or total, of the said elements and texts of any kind, is prohibited and will result in prosecution. September international expat APRIL INTERNATIONAL EXPAT A MEMBER OF APRIL Headquarters: 110, avenue de la République - CS Paris Cedex 11 - FRANCE Tel.: +33 (0) Fax: +33 (0) info@aprilmobilite.com - Public limited company with capital of 200,000 - Registered with Companies House in Paris under number Insurance broker - Registered with ORIAS (Organisation for the registration of insurance brokers) under number (ww.orias.fr) - Prudential Supervision Authority - 61, rue Taitbout Paris Cedex 09 - FRANCE. international Changing the face of insurance.

13 [ LA MOBILITÉ] INDIVIDUALS rystal Studies Application form APRIL International supports the Foundation for Nature and Mankind and Handicap International Changing the face of insurance.

14 Crystal Studies application form PLEASE WRITE IN CAPITAL LETTERS INSURED Person to be insured Insurance consultant reference number: I 1 Title: Mrs Miss Mr Date of birth: 00 /00 /0000 (upper age limit of 40) Surname: First names: Country of nationality: Country of destination: (Providing an address will allow you to receive information on your reimbursements) Reason for trip: Study Leisure Training Language course Au pair placement School or organisation which the insured attends: Address for delivery of correspondence: Postcode:00000 City: State/Region/Land/County: if outside Country: Telephone:00 /00 /00 /00 /00 /00 France I would like to receive my correspondence in: French English Spanish German d d m m y y y y 2 MEMBER = PERSON PAYING THE PREMIUM The insured is paying the premium (in this case, the address below is not required) Someone else is paying the premium Title: Mrs Miss Mr Date of birth: 00 /00 /0000 Surname: First names: Address: Postcode:00000 City: State/Region/Land/County: Country: Telephone: 00 /00 /00 /00 /00 /00 if outside France (Providing an address will allow you to receive information on your policy) I would like to receive my correspondence in: French English Spanish German d d m m y y y y During your period of insurance you can update your contact details at (Individuals). 3 PERIOD AND LEVEL OF COVER d d m m y y y y d d m m y y y y Period of cover required: from 00 /00 /0000 to 00 /00 /0000 for a duration of: 00.0months (minimum 1 month, maximum 12 months) Are you renewing an existing policy? Yes No Client reference number: C Type of cover selected: Complete cover or Mini cover 1 st euro or EHIC top-up Please note: you must send us a photocopy of your student card or current school attendance certificate before your policy can take effect. If you are going abroad to work as an au pair, please send us a copy of your contract with the host family along with your application form. 2

15 FOR MEDICAL EXPENSES, YOU CAN BE REIMBURSED BY: 4 cheque in euros bank transfer to a bank account in France. In this case, please send us details of your bank account. bank transfer to an account in the USA. International bank details are required including the IBAN number, SWIFT code, your bank's address, sort code and an ABA routing number. bank transfer to an account in other countries. International bank details are required including the IBAN number, SWIFT code, your bank's address. Bank charges will be deducted from any payment over the equivalent of 75. Bank charges are shared for all transfers (of any amount) carried out within the Euro zone. Your reimbursement statements are available by or on your insurance website. If you would also like to receive a paper version, please tick this box: OTHER INFORMATION FOR THE COMPLETE OPTION 5 In the event of death I name as beneficiary: My surviving spouse on condition that we were not legally separated when the lump sum became payable, second, equally, my children living, unborn or represented as such; third, equally my ascendants and fourth my other heirs. Other beneficiary: Surname: First names: d d m m y y y y Date of birth: 00 /00 /0000 Place of birth: CALCULATION OF PREMIUM 6 Minimum period of cover: 1 month; maximum period of cover: 12 months. Depending on your age band, the choice of cover (1 st euro or EHIC top-up) and the payment method selected (full payment on application or monthly instalments), go to page 9 of the brochure to calculate your premium. Monthly premium (all taxes included) for your level of cover: 00 Number of months required: 00.0 Total premium (all taxes included): 000 SELECTION OF PAYMENT METHOD Full payment at time of application by cheque or debit/credit card: 7 by cheque, please make them payable to APRIL International Expat by credit/debit card, please enter your card details below: Only Eurocard-Mastercard and Visa cards are accepted: Eurocard-Mastercard Visa Card number: 0000 /0000 /0000 /0000 Expiry date:00 /00 The last three digits of the security number printed on the reverse side of your card: 000 Cardholder: Payment in monthly instalments from a French bank account: Complete the direct debit authorisation and enclose bank details. 3

16 MAKING A DIFFERENCE WITH APRIL International On behalf of our sponsored associations, APRIL International invites you to support the protection of the environment or the improvement of living conditions of disadvantaged populations worldwide. I would like to make a donation to: 8 Handicap International To make my contribution: The Foundation for Nature and Mankind I will make a donation of: (to be added to my premium payment) and/or I will donate the cents from my healthcare reimbursements (available to beneficiaries only) If you are a French taxpayer, part of your donation is tax-deductible. For Handicap International, you can claim 75% of your donation up to 510 and 66% for higher amounts (capped at 20% of your net taxable income). For the Foundation for Nature and Mankind, you can claim 66% of your donation (capped at 20% of your net taxable income). You will automatically receive a tax receipt for any donation over 8. HEALTH STATEMENT 9 Insured s surname and first name(s): Deadline for signature of the Health statement: 6 months. If you would like your policy to start on 01/07/2012, you can sign this Health statement between 01/01/2012 and 30/06/2012. I declare that I am in good health and do not suffer from any disability or illness for which I am currently receiving treatment and which is likely to reoccur or develop. I declare that I have not undergone any medical treatment lasting more than one month during the last three years and do not plan to undergo any therapy, treatment or surgery in the country I will be visiting during the period of insurance cover. I declare that I do not expect to be hospitalised within 12 months of the effective date of my policy for any reason whatsoever (removal of tonsils or cysts, knee surgery, childbirth etc.). I authorise the Medical Examiner to request any information he considers necessary from the doctors who have treated me or whom I have consulted. I authorise these doctors to pass on the information, within the bounds of patient confidentiality, to the Medical Examiner. I confirm that I have answered all of the questions accurately and honestly and have neither included or omitted anything which could mislead the insurers of the present policy. THE INSURER'S MEDICAL EXAMINERS RESERVE THE RIGHT TO REQUEST FURTHER MEDICAL EXAMINATIONS. Any non-disclosure, intentional misrepresentation or inaccuracy altering the nature of the risk or influencing the insurers to reduce the risk will result in the cancellation of all cover under the policy. In such circumstances the premium will not be refunded (art. L113-8 of the French Insurance Code). If you cannot sign the health statement, please give us the reasons why: d d m m y y y y Signed in (city) Date 00 /00 /0000 Signature of the insured preceded by the words «I have read, understood and accepted the policy document»: Your Insurance consultant + APRIL International Expat Code: If the person to be insured is a minor, a parent or legal guardian must sign on his or her behalf: 4

17 SIGNING YOUR APPLICATION FOR INSURANCE 10 I hereby apply for membership of the Association of APRIL Mobilité Insured under their agreements with Groupama Gan Vie and ACE Europe. I have read the Association's statutes and regulations. I understand that, by choosing Personal liability (private capacity) cover and Legal assistance (included under the Complete Option), I am applying for insurance with Gan Eurocourtage and Solucia PJ. I have read the General conditions and booklet CS 2012 outlining the details of my insurance cover. I am aware of my right to cancel the insurance and accept the terms and conditions. I have retained a copy of these. I also understand the terms and conditions of APRIL International Expat s handling of my insurance cover. If my insurance cover is subsequently amended, I accept that the General conditions applied will be those outlined above. I have been informed that the information requested is required in order to process my application and that these details will be held electronically by APRIL International Expat, the insurer or their agent for the requirements of my insurance cover. Under the French Act of 6 th January 1978 (amended), I have the right to access and, if necessary, rectify any personal information held on file by writing to APRIL International Expat, 110 avenue de la République, CS 51108, Paris Cedex 11, FRANCE. APRIL International Expat has the right to use certain administrative information and to share it with associated businesses who may use it to make me aware of new products or services. A list of these companies is available on request. Under the French Act of 6 th January 1978 (amended), I have the right to prevent my details being passed on in this way by writing to APRIL International Expat at the above address. Postal charges will be refunded. I understand that telephone calls to APRIL International Expat may be recorded for administrative purposes and that I may have access to recordings made of my calls by writing to APRIL International Expat at the above address. I understand that each recording is kept for a maximum of 2 months. I understand that cover under the present policy does not exempt me from paying contributions to any state scheme to which I may belong. I agree to pay APRIL International Expat any reimbursements made to me by Social Security or any private healthcare insurer (unless an EHIC top-up cover has been selected). I confirm that I have answered all of the questions accurately and honestly and have neither included or omitted anything which could mislead the insurers of the present policy. d d m m y y y y Signed in (city) Date 00 /00 /0000 Signature of the insured preceded by the words «I have read, understood and accepted the policy document»: Signature of the member (if different from the insured) preceded by the words «I have read, understood and accepted the policy document»: DIRECT DEBIT AUTHORISATION FORM (to be completed if you are paying by direct debit) I hereby authorise my bank to effect transfers from my account, if adequate funds are available, on the instructions of the organisation named below. In the event of a disputed transaction I have the right to cancel the order by instructing my bank to do so. I will then settle the outstanding amount with the creditor. Name and address of the creditor: APRIL International Expat - 110, avenue de la République - CS Paris Cedex 11 - FRANCE National Issuer Number Surname, first names and address of account holder: Surname of account holder: First names of account holder: Street number: 000 Street type (ave., st., blvd, ): Street name: Postcode: City: Country: Account to be debited: Sort code: Branch code:00000 Account number: Transaction code:00 Name and address of the bank to be debited: Name: Street number: 000 Street type (ave., st., blvd, ): Street name: Postcode: City: Country: FRANCE d d m m y y y y Date: 00 /00 /0000 Signature: Please send this form to APRIL International Expat enclosing details of your bank, savings, or Post Office account. 5

18 Please send your completed application to: APRIL International Expat Service Adhésions Individuelles 110, avenue de la République - CS Paris Cedex 11 - FRANCE 6

19 APRIL International supports the Foundation for Nature and Mankind and Handicap International [ LA MOBILITÉ] INDIVIDUALS Changing the face of insurance. To cancel your policy, please use the tear-off slip below and send it to APRIL International Expat - 110, avenue de la République - CS Paris Cedex 11 - FRANCE CANCELLATION OF DOOR-TO-DOOR CONTRACT OF SALE Article L of the French insurance code Any person who is canvassed at their home or residence or place of work, even if this visit was at their own request, and who signs an insurance proposal or contract for a purpose which is not related to their commercial or professional activity, may cancel this agreement by sending a letter by recorded delivery with proof of receipt during a period of 14 days from the day of signature of the agreement without requiring to specify the reason for the cancellation or being subject to penalties. Conditions: If you wish to cancel your insurance policy, please fill in and sign this tear-off slip. You should then send it in a sealed envelope by registered letter with proof of receipt to the above address. It must be sent no later than 14 days on the day following signature of your application or, where the deadline expires on a Saturday, Sunday or a bank holiday or other non-working day, on the next working day. I, the undersigned, wish to cancel my application for insurance under the following policy: Policy name: Crystal Studies Ref/ CS 2012 d d m m y y y y Date of signature of application: 00 /00 /0000 Member s surname: Member s first name: Date of birth: d d m m y y y y 00 /00 /0000 Member s address: Postcode: City: Country: if outside France Telephone: 00 /00 /00 /00 /00 /00 Name of insurance consultant: Address of insurance consultant: Postcode: City: Country: if outside France Telephone number: 00 /00 /00 /00 /00 /00 Date and member s signature: Reserved for APRIL International Expat d d m m y y y y 00 /00 /0000 Client reference number C Your application step by step: > > Crystal Studies Application form Crystal Studies Mr MARINI Christophe The above person benefits from the direct payment of hospital fees. Kindly facilitate hospital admission calling one of the numbers noted on the other side of this card. Information Tél : +33 (0) Fill in your application form and send it to APRIL International Expat. If you need help, read the tips on the next page or contact us. Your application is processed within 24 hours. You will be sent: - your membership certificate serving as your insurance certificate, - the general conditions showing how your policy operates, - your insurance card containing emergency contact numbers for requesting assistance services or before admission to hospital. 7

20 [CRYSTAL STUDIES] TAKING OUT THE INSURANCE A. Fill in your personal details (surname, first name, address ) 1 and. B. Select the period and level of cover 3. C. Choose how you want to receive your healthcare reimbursements 4. D. If you are applying for the Crystal Studies "Complete" option, please designate a beneficiary in the event of death 5. E. Depending on your age band and your choice of cover (1 st euro or EHIC top-up) and the selected method for paying the premium (full payment on application or monthly instalments), refer to page 9 of the brochure to calculate the amount of your premium and fill it in 6. F. Select the payment type (full or monthly) and the payment method 7. G. If you would like to make a donation to one of our sponsored associations, fill in part 8. H. Complete, date and sign the Health statement 9. I. Date and sign the application form 10. J. Enclose with your application: a photocopy of your current student card or school attendance certificate (if you are going abroad to work as an au pair, please send us a copy of your contract with the host family) If you are paying in full: enclose a cheque in made payable to APRIL International Expat or provide your credit/debit card details on the application form If you are paying in monthly instalments: fill in the attached direct debit authorisation form enclose details of your bank account Send to APRIL International Expat - Service Adhésions Individuelles 110, avenue de la République - CS Paris Cedex 11 - FRANCE WHAT HAPPENS NEXT? Your application is processed within 24 hours, as soon as we receive your application form and supporting documents. Your insurance is evidence by the issue of a Membership certificate (serving as your insurance certificate) showing details of the cover you have selected and the effective date of your policy. Your policy will start on the date shown on the Membership certificate and, at the earliest, on the day following receipt of your application form and supporting documents. international expat 2 All the APRIL International Expat trademarks, logos, graphics and commercial material contained in this document are registered and are the property of APRIL International Expat. Any reproduction of any kind, either partial or total, of the said elements and texts of any kind, is prohibited and will result in prosecution. September APRIL INTERNATIONAL EXPAT A MEMBER OF APRIL Headquarters: 110, avenue de la République - CS Paris Cedex 11 - FRANCE Tel.: +33 (0) Fax: +33 (0) info@aprilmobilite.com - Internet: Public limited company with capital of 200,000 Registered with Companies House in Paris under number Insurance broker - Registered with ORIAS (Organisation for the registration of insurance brokers) under number ( Prudential Supervision Authority - 61, rue Taitbout Paris Cedex 09 - FRANCE Changing the face of insurance. 8