Travel Risk Insurance - Application Form - Allianz Global Assistance
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1Travel Risk Insurance
Including 24 hours help Allianz Global Assistance Emergency Centre
The Travel Risk Insurance offers you, as a traveller not residing in the Netherlands,
• additional travelling and accommodation expenses in case of illness or accident:
the oppurtunity of taking out both travel insurance and cancelletion insurance at an
costing price
attractive premium.
• additional return travel costs due to recall: costing price
• costs of repatriation by air ambulance: costing price
Cancellation insurance
• search and rescue costs: costing price
This insurance covers, only for journey booked in the Netherlands, indemnification
• costs of acquiring a laissez-passer or replacement visa in case of loss: € 115,-
for:
• cancellation expenses
Premium
• holiday days outstanding in case of premature termination or interruption
• Europe, including the Netherlands and the non - European countries on the
• holiday days outstanding in case of delayed departure (up to a maximum of
Mediterranean: € 2,- per person per day
3 days)
• World € 3,- per person per day
• Coinsuring winter sports/underwater sports/special sports (only in Europe)
due to, among other things:
€ 1,15 per person per day.
• serious illness, accident or death affecting you, your travelling companions or
relatives
Minimum premium: € 11,50
Costs: € 4,50
• extensive damage to property as a result of fire, storm etc.
Premium: 5% of the travel sum (excl. insurance tax)
Particulars
The insurance policies can only be taken out for persons who, on the commencing
Travel insurance (maximum term of validity: 2 months)
date of the insurance, have not yet reached the age of 70. For a complete description
This insurance covers, among other things:
of the insurance policies, please refer to the certificate of insurance and the
• medical expenses in case of illness or accident, up to a max. of € 30.000,-
insurance conditions.
(excess € 45,- per person)
Application form
1) Name and first initials
male
female
Date of birth
Address
Zipcode
Town
Country
Type of ID
No. of ID
2) Name and first initials
male
female
Date of birth
Type of ID
No. of ID
Wish to take out the following insurance (tick where applicable)
Cancellation Risk Insurance for a period of:
days
Commencing date:
Destination
Total travel/rental sum of all insured persons together €
Travel Risk Insurance for a period of:
days (max two months)
Commencing date:
Valid in:
Europe
World
Additional cover for:
winter sports
underwater sports
special sports
The premium must be calculated on the basis of all days of travel
The Travel Risk Insurance shall never be valid in the country in which the
Your Travel Agency:
insured, according to his passport, visa or other official travel document,
has his temporary and/or permanent residence
Country:
Date:
Town:
Signature:
How can we help?
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