Application form

OOM Schengen Visitor Insurance

Date 16-03-2018
Application number 7483379

Insurance details
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Product OOM Schengen Visitor Insurance

Desired commencement date 29-05-2018
Desired expiry date 08-08-2018

Policyholder
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Name Mrs/Ms A.V. Ramirez

is the applicant (policyholder) one of the No
insured persons?
Nationality Dutch
Address Korenmaat 11
SCHIPLUIDEN
NETHERLANDS
Telephone number 0612617824
Email address mimiarjen@gmail.com
Correspondence language English

Health declaration
●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

Do any of the persons to be insured have No

reason to expect admission to a hospital
or similar establishment within the
duration of the insurance?

Insured persons
●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

Mr R. Ramirez
Date of birth 09-12-1987
Nationality Philippine

Page 1 of 3

specialised
insurance
 Desired insurance
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Health insurance Yes

Mr R. Ramirez

Third party insurance for private Not selected

individuals

Details
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Existing ailments and symptoms

I am aware of the exclusions which apply Yes
to this insurance. I know there is no cover
for ailments and complaints that already
existed before the insurance was taken
out, even if the ailment or complaint was
not known at the time.

Premium calculation
●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●

OOM Schengen Visitor Insurance

09-12-1987 € 136.80
R. Ramirez

Policy costs € 0.00

Premium total € 136.80 Single payment

The premium includes € 0.00 insurance tax.

[]

[Creditcard]
[Deze premie is voldaan via creditcard.]

Application form OOM Schengen Visitor Insurance Page 2 of 3

 Acceptance statement
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The applicant/policyholder has taken note of the exclusions, in particular the exclusion of existing
ailments and complaints, and he/she has declared to agree hereto.

Exclusion of existing ailments and complaints

Under this insurance there is no claim for the reimbursement of costs resulting from ailments, symptoms
and/or physical defects which the insured person is suffering or has suffered on or before the
commencement date of your insurance, including ailments, symptoms and physical defects of which the
insured person was unaware. Nor do we reimburse any costs associated with the ailment, symptom or
defect.

Other exclusions
Costs relating to pregnancy and delivery are, among other things, also excluded. A full summary of the
exclusions may be found in the policy terms and conditions.

The applicant/policyholder declares:

to have answered all questions in this health declaration completely and truthfully;
to have taken cognisance of the information with regard to the OOM Schengen Visitor Insurance
coverage on OOM Verzekeringen's website (www.oomverzekeringen.nl);
to have taken cognisance of the premium;
to have taken cognisance of the policy terms and conditions which he/she has been presented
with in step 4 of the online application, including the complaints and disputes regulations;
to have taken cognisance of the content of the "Ken uw rechten" (Know Your Rights) brochure and,
as a consequence, to have taken cognisance of the scope of the obligation to disclose, the
incidents and fraud policy, and the use of personal data;
to agree to the applicability of the policy terms and conditions that are associated with this
application and form an integral part of the policy;
to be aware that he/she must accept the issued policy and pay the premium and any insurance
tax as soon as OOM Verzekeringen has received his/her online application and decides to
accept the insurance policy. He/she is however entitled within 14 days after receipt of the policy
to cancel the insurance and return the policy to us.

Date 16-03-2018

Application form OOM Schengen Visitor Insurance Page 3 of 3

OOM Verzekeringen
Postbox 3036 T +31 (0)70 353 21 00 E info@oomverzekeringen.nl IBAN NL91ABNA0511615140
2280 GA Rijswijk, Nederland F +31 (0)70 360 18 73 I www.oominsurance.com BIC ABNANL2A

The trade name OOM Verzekeringen is used by OOM Holding N.V. (KvK The Hague 27194193), OOM Global Care N.V. (AFM 12000623, KvK The Hague 27111654), OOM Schadeverzekering N.V. (AFM 12000624, KvK The Hague 27155593)
and "O.O.M." Onderlinge Molestverzekering-Maatschappij U.A. (KvK The Hague 27117235). These companies are registered in The Hague and share operational offices in Rijswijk.