AVI Insurance

Insurance holder.

Insurance trip.

	Mrs Ms Mr
Family Name
First Name
Date of birth
email
Home country

Destination country

Departure date
(day/month/year)

Return date
(day/month/year)

month(s)

46 € (International worldwide)
24 € (European in Europe)

€

- surcharge 50% for people over 40 -

Your optional coverages.

High risks coverage (18 €/week)
more details.

No Yes

week X 18 €

€

Total

€

If I am not fully satisfied, I will immediately return the personal insurance card/s for refund. I hereby declare that I am in good health and clearly understand that all consequences from any illness or accident prior to my insurance coverage starting date as above mentioned are not covered, nor are any effects or consequences of the HIV virus or Hepatitis C transmission.I also declare that I did not receive any medical treatment for the last 6 months and I do not plan to receive any medical care abroad.

I confirm that I have read, understood and accept, AVI International Insurance Conditions.