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3ROLĠDGHDVLJXUDUHGHFăOăWRULHvQVWUăLQăWDWHQUVOJ089822290
Travel insurance policy no. VOJ089822290
ÌQED]DFRQGLĠLLORUGHDVLJXUDUHúLvQVFKLPEXOvQFDVăULLSULPHLFRQWUDFWXDOHFRUHVSXQ]ăWRDUH$//,$1=ğ,5,$&$6,*85Ă5,6$DVLJXUă
pe: (Throughout Terms and Conditions and in the exchange of contractual premium collection, ALLIANZ TIRIAC ASIGURARI S.A. insures)
Nume (Surname): Dutcovici Prenume (First Name): Alexandru
&131USDúDSRUW(Serial ID): 1930804226770 'DWDQDúWHULL(Date of birth): 04.08.1993
Tel. (Telephone no.): 755979612 Email (E-mail address): dutcovici.alexandru@gmail.com
Adresa ORFVWUQUMXGHĠVHFWRU : Bucuresti; Str. -; Nr. -; Bl. -; Sc. -; Ap. -;
(Address: town, street, no., county)
3HULRDGDDVLJXUăULL(Insurance period) De la: (From) 10.09.2019 3kQăOD(Until) 17.09.2019
$FRSHULUHWHULWRULDOă %XOJDULD*UHFLD7XUFLD,WDOLD6SDQLD3RUWXJDOLD&URDWLD&LSUX0DOWDFXH[FHSĠLDĠăULLGHUH]LGHQĠăD$VLJXUDWXOXL
(Teritoriality) (Bulgaria, Greece, Turkey, Italy, Spain, Portugal, Croatia, Cyprus, Malta with exception of rezidential country of the Insured)
6XPDDVLJXUDWăSHQWUX$VLJXUDUHD Cheltuieli medicale 30.000 EUR din care: cheltuieli de repatriere 10.000 EUR; cheltuieli medicale ca urmare a unui puseu acut al unor
Medicala: afectiuni pre-existente sau boli cronice 1.000 EUR
(Sum insured for Medical (Medical expenses 30.000 EUR including repatriation expenses 10.000 EUR and medical expenses as a result of acute flare of pre-
Insurance) existing condition or chronic disease 1.000 EUR)
6XPDDVLJXUDWăSHQWUX$VLJXUDUHDGH$FFLGHQWH3HUVRDQH(Sum insured for
2.500 EUR
Personal Accidents Insurance):
6FRSXOFăOăWRULHL Turism Sport de agrement 0XQFă
(Travel scope) (Turism) (Recreational Sport) (Work)
3ULPDWRWDOăGHDVLJXUDUH (Insurance premium): 27 RON Data emiterii: (Issue date) 13.08.2019
352&('85Ă'(850$7Ì1&$='(85*(1ğĂ PROCEDURE TO BE FOLLOWED IN CASE OF EMERGENCY
În cazul producerii evenimentelor acoperite prin $VLJXUDUHDPHGLFDOă In case of occurrence of any event covered through Medical Insurance, the
$VLJXUDWXOVDXXQUHSUH]HQWDQWDODFHVWXLDWUHEXLHVăUDSRUWH]HXUJHQĠD Insured or his/her representative has to report medical emergency
PHGLFDOăLPHGLDWOD&RPSDQLDGHDVLVWHQĠă immediately to the Assistance Company:
MONDIAL ASSISTANCE GmBH MONDIAL ASSISTANCE GmBH
Pottendorfer Strasse 23-25, A-1120 Wien, Pottendorfer Strasse 23-25, A-1120 Wien,
Tel.: 00 43 (1) 525 03 53, 00 40 (21) 312 22 39, Tel.: 00 43 (1) 525 03 53), 00 40 (21) 312 22 39,
sau Centrul de Daune Allianz-Tiriac Asigurari: 0040 (21) 201 91 81 or Claim Center Allianz-Tiriac Asigurari: 0040 (21) 201 91 81
VăRIHUHXUPăWRDUHOHLQIRUPDĠLL to provide the following information:
ƒQXPHOHúLSUHQXPHOH ƒ name and surname
ƒQXPăUXOSROLĠHLGHDVLJXUDUH ƒ insurance policy number
ƒQXPăUXOGHWHOHIRQúLDGUHVDODFDUHSXWHĠLILFRQWDFWDWvQVWUăLQăWDWH ƒ telephone number and contact address details from abroad;
ƒPRWLYXOSHQWUXFDUHVROLFLWDĠLDVLVWHQĠă ƒ reason for requesting assistance
úLVăUHVSHFWHLQVWUXFĠLXQLOHSULPLWHGHOD&RPSDQLDGH$VLVWHQĠă and to follow the instructions received from the Company of Assistance;
În cazul producerii evenimentelor acoperite prin Asigurarea Storno, In case of occurrence of the events covered by Storno Insurance, the Insured
$VLJXUDWXOVDXXQUHSUH]HQWDQWDODFHVWXLDYDDQXQЙD&RPSDQLDGH or his/her representative shall notify the Assistance Company within 2 working
$VLVWHQЙăvQWHUPHQGH]LOHOXFUăWRDUHODQXPHUHOHGHWHOHIRQGHPDL days at the above telephone numbers or at the e-mail address
sus sau la adresa de e-mail Daune_AZ_Tiriac@mondial-assistance.at. Daune_AZ_Tiriac@mondial-assistance.at.
În cazul producerii evenimentelor acoperite prin contractul de asigurare, For the events covered through the current insurance contract (except those
DOWHOHGHFkWFHOHDFRSHULWHSULQ$VLJXUDUHD0HGLFDOăɁL$VLJXUDUHD6WRUQR covered through Medical Insurance ans Storno Insurance), the Insured or
$VLJXUDWXOVDXXQUHSUH]HQWDQWDODFHVWXLDWUHEXLHVăDYL]H]H$VLJXUăWRUXO his/her representative has to notify the Insurer in 5 days from his/her return to
vQWHUPHQGH]LOHOXFUăWRDUHGHODvQWRDUFHUHDvQĠDUă the residential country.
$POXDWODFXQRVWLQĠăGHFHOHvQVFULVHvQ&HUHUHDGH$VLJXUDUH&RQGLĠLLOH I have been notified with respect to the Application Form and Terms and
GH$VLJXUDUHúLGHFODUSHSURSULDUăVSXQGHUHFăGDWHOHLQFOXVHvQ&HUHUHD Conditions and I declare on my own responsibility the dates included in the
GH$VLJXUDUHVXQWUHDOHúLvQFRQIRUPLWDWHFXLQIRUPDĠLLOHGHFDUHGLVSXQ Application Form are real and in agreement with the information I set,
DVWIHOVXQWGHDFRUGFXvQFKHLHUHDFRQWUDFWXOXLvQDFHVWHFRQGLĠLL therefore, I agree to conclude the insurance contract under this conditions.

3UH]HQWDSROLĠăHVWHvQFKHLDWăvQGRXăH[HPSODUH(The current policy is concluded in two indents.)

ASIGURAT (Insured) INTERMEDIAR (Intermediarry) $6,*85Ă725(Insurer)

DUTCOVICI ALEXANDRU INSIA EUROPE SE, PRAGA - SUCURSALA
BUCURESTI
QXPHVHPQăWXUă(name, signature) QXPHVHPQăWXUă(name, signature)

6&$OOLDQ]ğLULDF$VLJXUăUL6$ &DSLWDOVRFLDOVXEVFULVúLYăUVDWOHL
6WU&ăGHUHD%DVWLOLHLQU Înregistrat la ORC sub nr. J40/15882/1994, CUI: 6120740
6HFWRU%XFXUHúWL5RPDQLD 6RFLHWDWH$XWRUL]DWăGH$XWRULWDWHDGH6XSUDYHJKHUH)LQDQFLDUă
Telefon 021 2082 222 &RGXODORFDWvQ5HJLVWUXO$VLJXUăWRULORUúLUHDVLJXUăWRULORU RA-017
Fax 021 2082 211 Codul LEI 529900XKNXM9MBH8GS45
www.allianztiriac.ro 1 Operator de date cu caracter personal nr. 779
SR EN ISO 9001:2015