Travel Insurance
Globe Partner Association
As a member of the Globe Partner Association, you have selected the cover that the Association has taken out with:•

MGEN, 3-7 Square Max Hymans, 75648 Paris Cedex 15, registered under number SIREN 775 685 399, and MGEN
Vie, 3-7 Square Max Hymans, 75648 Paris Cedex 15, registered under number SIREN 441 922 002, regulated by
the French Mutual Insurance Companies code, under policy no. MGENIB1100009SAP/01 for the Health andrepatriation benefits and Death benefits. MGEN outsources the coverage of costs of medical repatriation andassistance to Mutuaide Assistance.

•

Chubb European Group SE, La Tour Carpe Diem, 31 Place des Corolles, Esplanade Nord, 92400 Courbevoie
France, limited company with capital of 896,176,662 €, governed by the French insurance code, RCS Nanterre
450 327 374 – per the intermediary of VYV International Benefits, under the policy no. FRBOPA61611 for the
luggage insurance benefits and under the policy no. FRBOPA61610 for the accidental death & disability benefits
and for the legal liability benefits.

The administration of these benefits is delegated to ACS, 153 rue de l’Université, 75007 Paris, simplified limited company
with a capital of €150.000, insurance brokerage firm registered RCS Paris under no. 317 218 188, ORIAS no. 07 000 350.
How the cover is applied and the details of the benefits to which you are entitled are set out in this leaflet. In case of
discrepancy between the English version of this leaflet and the French version of the contract, the French version of thecontract will prevail.

Contents
1/ General provisions ................................................................................................................... 2
2/ Definitions ............................................................................................................................... 3
3/ Medical expenses, accidental death and dismemberment benefits ............................................... 5
4/ Assistance benefits................................................................................................................. 10
5/ Legal liability.......................................................................................................................... 12
6/ Luggage ................................................................................................................................ 13
7/ Excluded risks for all benefits .................................................................................................. 14
8/ Basis of the insurance contract ............................................................................................... 15
9/ Data Protection ...................................................................................................................... 17
10/ Mediation ............................................................................................................................ 18
11/Authority in charge of overseeing insurance companies ........................................................... 19
12/ Consumer’s right to object to telephone marketing ................................................................. 19
13/ Schedule of cover................................................................................................................. 20
14/ Medical claim form ............................................................................................................... 21
Annex : Privacy notice ACS ......................................................................................................... 22

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1/ General provisions
Eligibility – Enrolment
Members of the Globe Partner Association, under 70 years of age, of Japanese nationality or South Korean withpermanent resident status in Japan, travelling outside of their country of residence to countries of the European Union,
are eligible on an optional basis.
The Member must subscribe the initial contract the day of departure at the latest in order to benefit from the guarantees.
Exceptionally, the Member may subscribe after the day of departure subject to the sending of a declaration on his honour
stating that he/she does not subscribe for a known and/or immediate medical purpose.
The renewal of the contract (by the subscription of a new one) will only be accepted if the next contract immediately
follows the previous one without any interruption.
Upon enrolment, the Member must fill in the enrolment documents which include a health declaration and on which shallread the coverage opted for and the corresponding premium amount. The chosen option cannot be modified during theperiod of coverage.
The Member shall pay for the entire period of coverage on subscription.
Acceptance of coverage may be subject to further information the Insurer considers necessary.
Upon acceptance to the insurance, the Member and his dependants if any shall be referred to as “Insured”.
The guarantees of the contract, subject of this information booklet, will not apply in the country of residence of the
Insured.
Commencement of cover
Coverage applies for each eligible person upon acceptance from the Insurer and the payment of the premium.
The travel insurance policy GLOBE PARTNER JP is concluded for a fixed term and not eligible for the right renunciation
provided for in Article L.112-2-1 of the French insurance code or L.221-18 of the French Mutual Insurance Companies
code.
Termination of coverOnce admitted to insurance - and subject to the clauses of the French insurance code or French Mutual Insurance
Companies code regarding false declaration -, the Insured cannot be excluded from the coverage as long as he fulfils theconditions.
The contract can be subscribed for a period of twelve (12) months maximum through one or several contracts. Any newcontract must be authorized by the Insurer.
In any case, coverage shall end:
for each Insured:on the date of final return in case the contract period has not ended,
after evacuation to his country of residence,on the last day of his period of coverage, the date on which he ceases to be a Member of the Globe Partner
Association,in case of dissolution of the Globe Partner Association or judicial liquidation of the Insurer,
For the totality of the Insured, at the time of effectiveness of the cancellation, per risk, of the following contracts:• group policy n° MGENIB1100032SAP between the Globe Partner Association and MGEN and MGEN Vie,• group policy with optional membership n° FRBOPA61610 & FRBOPA61611 insured by Chubb European Group SE.
Termination of benefits (or suspension) means the end of benefits for the Insured for all medical acts
incurred after the termination date of coverage.

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Modification or cancellation of the contract
Any modification of date or cancellation of the contract can only be accepted if it was notified before the effective date of
the contract.
It is possible to change dates once only and within the limits of the current civil year.
In case of cancellation, the contract can only be refunded on presentation of supporting documents and 60 € will be
retained from the premium.
Sanctions in case of false declaration
Any information supplied by the Insured or one of their beneficiaries that is incorrect, falsified, exaggerated or any
fraudulent acts on their part shall be the direct responsibility of the Insured and shall give rise to:
the nullity of your contract in case of intentional misrepresentation (113-8 of French insurance code or L.221-14 of
the French Mutual Insurance Companies code),
premiums paid are kept by the Insurer, who is entitled, as a compensation, to the payment of all premiums due; insuch a case, the Insured will have to reimburse all the claims paid by the Insurer under the contract;
if the intentional misrepresentation, discovered before any claim, is not established, premium increase or terminationof the contract (113-9 of the French insurance code or L.221-15 of the French Mutual Insurance Companies code)
if the intentional misrepresentation, discovered after the claim, is not established, decrease of claim according to theratio between the paid premium and the premium that should have been paid if the initial declaration had been
consistent with the reality (113-9 of the French insurance code or L.221-15 of the French Mutual Insurance
Companies code).
You will have to reimburse all the claims that were improperly paid to you under the contract, subject to this information
booklet.

2/ Definitions
The terms and expressions used in this booklet shall have the following definition:
Accident: any bodily harm not premeditated by the insured and resulting from the sudden and unexpected effect froman external cause – excluding chronic or acute illnesses.
Attack / Acts of terrorism: any act of violence, constituting a criminal or illegal attack, against persons and / orproperty, in the country in which you reside, aimed at seriously disturbing public order. This "attack" should be recordedby the French Ministry of Foreign Affairs.
Claim: any event that may trigger coverage under this contract.
Civil war: armed opposition of several parties belonging to the same country, as well as any armed rebellion, revolution,
sedition, insurrection, coup, under martial law or border closure commissioned by local authorities.
Consequential damage: any financial loss which is the consequence of the loss of use of a right, of the interruption ofa service provided by a person or personal or immovable property, or of the loss of a benefit, and which is the directconsequence of damage to the persons and property insured hereunder.
Country of residence: country in which is located your tax and legal residence.
Damage to property: any harm done to, destruction of, change in, loss or disappearance of an, item, object or
substance, and also any physical harm done to an animal.
Disease or Illness: deterioration in health established by a medical authority, requiring medical treatment.
Deductible: the amount of the compensation payable by you.
Dental fees further to an accident: treatment must be performed within 15 days following the date of the accident
and consists of replacement of the sane and natural teeth which were lost or damaged.
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Emergency: term used in case of accident or commencement of a serious covered illness requiring urgent medical
attention and treatment of the Insured. Only medical treatment given by a doctor, general practitioner or specialist and ahospitalisation intervention in the twenty-four (24) hours following the direct cause of the emergency will be considered
as conditions to be reimbursed.
Epidemic: rapid spread of an infectious and contagious disease affecting a large number of people at a given place andtime, reaching at least level 5 according to the World Health Organization’s criteria.
European Union: Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France,
Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal,
Romania, Slovakia, Slovenia, Spain, Sweden, United Kingdom. By derogation, Norway, Switzerland, Monaco, Andorra and
Liechtenstein are among the countries covered by the contract, which is the subject of this information booklet.
Foreign war: armed opposition declared or not from a State to another State, as well as any invasion or state of siege.
Forfeiture: the loss of any warranty claims.
Home address: by home address is meant your principal and usual residence in your country of residence.
Insured person: party(ies) covered by the insurance contract, object of this information booklet.
Insurance Code / Mutual Insurance Companies code: collection of laws and regulations governing the insurance
contract according to the Insurer.
Members of the immediate family: The father, the mother, brothers and sisters.
Natural disasters: abnormal intensity of a natural agent not resulting from human action.
Obsolescence: depreciation of the value of a property caused by time, use or maintenance conditions on the day of theloss. Unless otherwise stipulated in the contract, the old age applied for the calculation of the indemnity due is 1% permonth up to a limit of 80% of the original purchase price.
Pandemic: worldwide spread of a disease.
Personal injury: any bodily harm suffered by an individual and the ensuing losses.
Personal items: only personal items with a purchase date of less than 3 years will be covered. The benefit is acquired
only during the outward and return journeys.
Pollution: deterioration of the environment resulting from the introduction into the air, water or land of substances
which are not naturally present in the environment.
Risk: unintentional, unpredictable, irresistible and external event.
Strike: collective action resulting in a concerted cessation of their activity by employees of an undertaking, an economic
sector, a professional category aiming at supporting claims.
Subrogation: a legal situation by which the rights of a person are transferred to another person (especially in case of
substitution of the Insurer for Subscriber in view of suing the adverse party).
Third party: any person other than the Insured responsible for damage, to the exclusion of a family member. Are
considered as Third party the members non-belonging to one family.
Transport company: any company duly approved by the public authorities for the transport of passengers.

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Waiting period/ qualifying time: period during which the Insured is not entitled to certain benefits.
Usual Residence: usual residence corresponds to the fiscal residence of the Subscriber.

3/ Medical expenses, accidental death and dismemberment benefits
Area of coverBenefits apply, outside of the country of residence of the Insured, in countries of the European Union.
Outside the area of cover, the Medical expenses cover also applies for tourist stays of less than three (3) weeks all over
the world with the exception of the country of residence of the Insured.
A/ Medical expenses benefits
Coverage consists of reimbursement of medical expenses paid by the eligible Insured to cover for medical acts and careas stated in the plan opted for. Benefits are limited to medical fees resulting from an accident or illness which are coveredby the French Securité Sociale notwithstanding the further exclusions.
Reimbursement requests will be accepted only if the Insurer estimates that the amount of the bills and receipts that havebeen sent is reasonable and habitual in the country where treatment is received. If not, the insurer is entitled to reduce
the amount of reimbursement.
The benefits for medical expenses end if our medical team deems that the Member can be repatriated tohis country of residence.
It is agreed and understood that whenever the insured person benefits or may benefit from the reimbursements of theFrench Sécurité Sociale in the European Union, benefits shall be paid as a complement.
In France, visits to doctors (general practitioners or specialists) are covered up to a maximum of €100 per visit.
Furthermore, in France, in non-contracted hospitals, the reimbursement of hospitalization expenses is limited to 80% ofactual costs.
Maximum amount for medical expenses per beneficiary and per year is €150 000.
Limit to actual costs / expenses
In accordance with article 9 of law 89-1009 of December 31, 1989 and decree 90-769 of August 30, 1990,
reimbursement or indemnification of fees due to illness or accident cannot exceed the amount of fees due by the Insured
after reimbursements of any nature he is entitled to.
Coverage of the same nature contracted to other insurance companies apply up to the limit of each benefit whatever thedate of subscription. Within this limit the beneficiary of the contract can obtain an additional indemnity joining details of
reimbursement provided by the other companies.
For application of the above-mentioned clause, the limit of the amount of fees left to the Insured is indicated by the
Insurer for every covered medical expense.
In case of undue payments: the beneficiary of the benefit commits to repay to the Insurer, as soon as possible, theundue claims. As a consequence, the Insurer can make compensation between these amounts and any other benefits
due by the Insurer to the Insured.
Excluded benefits from medical expenses
Benefits which are not covered by the French Sécurité sociale are excluded from the scope of this contract
as well as the following expenses:
1. expenses incurred before or after period of coverage,
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2. transportation fees of general practitioner which are not covered by Sécurité Sociale,
3. treatment and care non-prescribed by a qualified physician,
4. medical fees for which the insured could have waited for the return to his country of residence,
5. medical fees incurred in the country of residence,
6. cosmetic treatment and surgery unless consecutive to an accident,
7. congenital disability, hereditary diseases, and chronic illnesses,
8. medical aids including hearing aids and dental prosthesis,
9. dental care (except in case of emergency and accident),
10. stomatology, treatment of acne, and speech therapy,
11. optical care, orthoptics and contact lenses,
12. acupuncture, massages and physiotherapy unless consequent to a covered accident which resulted in a
hospitalisation,
13. psychotherapy including consultations,14. mental diseases including nervous breakdowns, treatment and care related to sleep disorder
15. HIV infection and its consequences, AIDS and its consequences,
16. sexual transmitted diseases (STD) and related tests,
17. thermal cures, and rehabilitation centres,
18. health check-ups,
19. vaccination fees,
20. medical expenses related to birth control, abortions, and sterility treatments, sexual dysfunctions,21. expenses related to pregnancy, and maternity,
22. expenses incurred for organ acquisition,
23. any operation or treatment related to a sex change,
24. non-prescribed drugs, non-medicinal products of current use such as medical alcohol, cotton, sunlotions, dental hygiene products, bandages, shampoos…,
25. subsidiary expenses such as telephone in case of hospitalisation or fees considered extravagant,unreasonable or unusual considering the country where they incurred.
Medical examination and arbitration
Doctors and authorised representative of the Insurer shall have access to the Insured in order to assess his state ofhealth. Upon request of the Insurer, the Insured shall provide any evidence and be performed any test or examination.
The insured shall be notified by registered mail of all the decisions taken by the Insurer further to the conclusions of its
medical adviser. The Insured may object the decision within 10 days by means of a detailed medical certificate addressedto the Insurer by Registered mail.
In case of disagreement on the state of health of the Insured, an amicable cross-examination by a physician chosen by
the Insured and a physician appointed by the Insurer may be performed.
If both doctors cannot reach the same conclusions, they designate a medical arbitrator for final settlement. Fail a mutual
choice, designation shall be judiciary.
Each party shall support the fees of its physician and share the ones of the arbitrator.
B/ Accidental death and dismemberment benefits•

Death benefit

In case of death of the Insured, a lump sum payment of €1 000 is paid to the Insured in order of preference:- the spouse,- failing this, to the children of the Insured who have been born or are to be born, in equal shares the share of thepredeceased being transferred to their own children or to their brothers and sisters if there are no children,- failing this, to the father and mother, in equal shares or to the survivor in the event of predecease,- failing this, to the legal heirs.
•

Accidental death benefit:

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A lump sum payment of €8 000 is paid to the Insured in case of accidental death (see definitions), provided deathoccurs within one year of the accident.
The amount of cover in the event of death of the Insured becomes payable in order of preference: the spouse, failingthis, to the children of the Insured who have been born or are to be born, in equal shares the share of the predeceased
being transferred to their own children or to their brothers and sisters if there are no children, failing this, to the father
and mother, in equal shares or to the survivor in the event of predecease, failing this, to the legal heirs.
•

Permanent disability benefit further to an accident:

A lump sum payment is paid to the Insured if he becomes disabled further to an accident, provided disability occurs
within one year of the accident and provided the accident occurs before his 70th birthday.
Disability is deemed TOTAL when according to the scale and the rules of evaluation it reaches 100%. In this case total
amount shall be granted.
Otherwise disability is deemed PARTIAL and the percentage of the lump sum for the corresponding disability shall only be
granted.
The maximum amount shall be €30 000 in case of permanent disability further to an accident.
Excluded risks for accidental death and dismemberment benefits
1. accidents caused by blindness, paralysis, mental illnesses, and all pre-existing diseases andinfirmities at the time of entering into the contract,
2. accidents caused by the use of a motor cycle with a cylinder in excess of 125 cm3 either as driver orpassenger,
3. accidents resulting from your professional activity,
4. accidents caused by a transport company not authorized for the public transport of persons,
5. accidents resulting from exercises carried out under military authority.

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SCHEDULE OF COVER
Death capital
Accidental Death capital sum
Total permanent disability capital sum
Scale of disablement:
Complete loss:of the armof the forearm or handof the thumbof the index fingerof the middle fingerof the third fingerof the little finger€1 000€8 000€30 000
Right*
75 %
65 %
20 %
16 %
12 %
10 %
8%

of the thigh

Left*
60 %
55 %
18 %
14 %
10 %
8%
6%
60 %

of the leg

50 %of two limbs

100 %of the foot40 %of the big toe

5%of the other toes3%of both eyes

100 %of sight of an eye

30 %complete deafness, incurable and not treatable

40 %complete deafness, incurable and not treatable in an ear

15 %total or incurable insanity

100 %*if it has been medically established that you are left-handed, the disability rate allocated for the right arm applies to the leftarm, and vice versa

Disability rates not included in the scale are determined by comparing their severity with the cases listed above without
taking into account the victim's occupation. By loss is meant the complete amputation or total paralysis of the limb inquestion, or the definitive and permanent ankylosis of all the joints which compose it.
The benefits paid by the Insurer are complementary to those of any other social security scheme or any supplementarybody of which it could benefit personally, in particular the benefits guaranteed by the European health card.
How to claim medical, accidental death and dismemberment expenses:
The Insurer is entitled to ask any Member or dependant to provide the necessary information related to their personal
data and claims for reimbursement. The Insurer will be authorised to have access to their medical files, respecting thelegal requirements of confidentiality.
Any information provided by the Insured or by one of his Dependants that turns out to be erroneous, falsified or
exaggerated or any fraudulent action of their own will involve the direct responsibility of the Insured and the recovery of
the amounts of money paid by the Insurer without due cause on this incorrect basis.
In case of hospitalisation, surgical intervention, X-ray or medical treatment, a medical certificate must first be requested
from us. It will be sent back to us, addressed to our medical examiner, after having been filled in by your doctor. In caseof non-respect of this provision, we are entitled to deny coverage. In case of hospitalisation the Insured can ask for a full
acceptance of liability in order to prevent him to advance fees.

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Medical expenses:
For all requests for reimbursement you should send the following documentary evidence to:
ACS – Service medical,
To the attention of the Medical advisor
153, rue de l’Université - 75007 PARIS, France
Tel. 00 33 (0)1 40 47 91 04 - Fax. 00 33 (0)1 47 05 11 84
E-mail : servicemedical@acs-ami.com
within a maximum deadline of 3 months following the date of expiry of the contract:
your certificate number, original invoices from doctors and medical establishments, and prescriptions forcorresponding medicines;
for medical expenses less than 500 €, it is possible to send us all the parts of your refund request by email tothe attention of the medical advisor at the address: servicemedical@acs-ami.com.
Nevertheless, we reserve the right to ask you to send the original documents within two years of the date ofreimbursement in order to control the fraud.
If it is impossible for the Member to provide the originals, at the request of the Insurer, the beneficiary of theguarantee undertakes to return to him, as soon as possible, the services received on the basis of the scanned
documents. Thus, the Insurer may make any compensation between the sums due in this respect and the otherbenefits payable by the Insurer to the Member.
for costs of hospitalization of more than 24 hours, it is possible to obtain an undertaking to pay medical costs bycontacting our MEDICAL ASSISTANCE service in Paris beforehand, which is available 24 hours a day Mutuaide,
medical@mutuaide.fr / 00 33 (0)1 55 98 71 68 (policy no. 4736).
The Insurer may require any further necessary document to process the claim.
No copy, photocopy or duplicate invoice is accepted by Post.
In case of death: the Death benefit will be paid if this event is declared, except in cases of force majeure, within the
period of six (6) months following the date of death, with following documents:- a natural death certificate issued by the doctor who pronounced the person dead,- a complete copy of the birth certificate of the deceased Covered Person,- a complete photocopy of the family register,- a copy of the birth certificate(s) of the beneficiary(ies),- the last tax notice in case of dependents.
In case of accidental death or dismemberment further to an Accident:
You must report the accident giving rise to a claim so that it reaches us within 5 working days unless there is anunforeseen event or a case of force majeure; if this deadline is not adhered to, and because of this we incur a loss, then
you will lose all rights to compensation.
Your accident report must be accompanied by the following documents as a minimum:
the initial medical certificate recording the injuries,
any statements made by witnesses of the accident,
the report or statement establishing the precise circumstances of the Accident.
During your course of treatment, you must be checked by our medical consultant so that s/he may assess theconsequences of the accident. You agree to undergo medical examinations that the medical consultant may decide toeffect and to provide us with all the elements necessary for the preparation of your case.
If you so wish, you may be accompanied by a doctor of your choosing.
If there is disagreement either in regard to the causes of death or the injuries, or the consequences of the accident for
which compensation may be payable, we will submit the differences of opinion to two experts, one chosen by you or yourlegal successors, the other chosen by us, subject to our respective rights. If there is still disagreement, a third expert will
be appointed, either by common agreement, or by the presiding judge of the Tribunal de Grande Instance de Paris,
giving an emergency ruling (“statuant au référé”).
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Each party is responsible for the payment of the fees and expenses of our experts. The fees of the third expert will beshared equally by both parties.

4/ Assistance benefits
Repatriation assistanceIf you find yourselves caught up in one of the situations referred to hereinafter, we will implement the services described,
following a simple telephone call (reversed charge or collect call accepted from abroad) or dispatch of an email, fax ortelegram.
In all cases, the decision to provide assistance and the choice of appropriate methods is at the sole discretion of the
Mutuaide doctor, after contacting the attending physician on site, and, where appropriate, the beneficiary’s family. Only
the medical interest of the beneficiary and compliance with the health regulations in force are taken into consideration
when making a decision regarding transport, the choice of method of transport, and the possible place of hospitalization.
Under no circumstances is Mutuaide a substitute for the local emergency assistance organizations.
What do we cover?
Repatriation or medical transport
If the Insured is ill or injured following a covered event and the Insured's state of health requires a transfer, if the local
medical infrastructure does not have the capacity to provide appropriate care, we organize and pay for repatriation to:- either the closest competent hospital- either the competent hospital closest to the Insured’s home in his country of residence- either the Insured’s home in his country of residence;
According to the seriousness of the case, repatriation and transport are effected under medical supervision, if necessary,by the most appropriate of the following methods:
special air ambulance
Regular airliner, train, sleeper, boat, ambulance.
Presence of relative/friend when hospitalized
If you are hospitalized and the state of your health does not allow you to be repatriated for seven days, we organize andpay for the cost of transporting a member of your family or a designated person who has remained in your country ofresidence so that they can come to your bedside in hospital.
We also refund the hotel costs for that person up to the amount indicated in the table of sums insured, and organize his
return upon your release from hospital.
This guarantee does not apply, if you are already accompanied by a family member on site.
Transport of the body in the event of death
In case of death due to a covered event, we will organize and pay for the transport of the body from the place where thebody was placed in the coffin to the international airport nearest your home address.
We will also pay for related costs necessary for the transport, including the cost of the coffin, thus enabling the transport,
up to the amount given in the schedule of cover.
The costs of the ceremony, all extras, interment or cremation, remain payable by the family.
Early return
If you have to terminate your trip prematurely in the event of accidental death or death as a result of a sudden illnessof a member of your immediate family (as defined under "Definitions") occurred in your country of residence, we will
cover your additional transportation costs on the basis of a round-trip economy class ticket, and those of your insured
family members, to allow you to attend the funeral, if the tickets for your and their return trip cannot be used as aresult of this event. The maximum duration of your stay must not exceed 21 days.

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Payment of search costs
We will pay for the costs of sea or mountain searches following an event which endangers your life, up to the amountgiven in the schedule of cover. Only the costs invoiced by a company duly authorized to carry on this kind of activity will
be reimbursed.
Advance of funds abroad
Following a theft or loss of your means of payment (credit card, check book …) or of your initial travel ticket, we will
advance you a sum of money up to the amount given in the schedule of cover, against the prior payment of anequivalent sum by a third party at the Allianz IARD registered office.
Dispatch of medicines abroad
We will pay the expenses of sending medicines essential to the continuation of an ongoing medical course of treatmentprescribed by a doctor, if you no longer have the medicine due to an unforeseen event, and it is impossible for you toprocure these medicines or their equivalent where you are.
The cost of this medicine remains payable by you in all circumstances.
Forwarding of messages
We are responsible for forwarding messages intended for you when you cannot be contacted directly, forexample, if you are in hospital.
Similarly, by calling us, a member of your family, may be given any message that you have left for their attention.
Legal assistance abroada) Payment of fees
We will pay the fees of legal representatives whom you call upon, up to the amount given in the schedule of cover, if you
are being prosecuted for unintentionally breaking the law of the foreign country in which you are traveling.
b) Advance of bailIf, due to unintentional violations of the legislation of the country in which you are traveling, the authorities require you
to put up bail, we will advance you a sum up to the amount given in the schedule of cover.
This advance must be reimbursed within one month following presentation of our request for reimbursement that wesend to you.
If the bail money is paid back before this deadline by the authorities of the country, it must be sent to us immediately.
What are the limits of our cover in case of force majeure ?
We cannot be held liable for failures in the execution of the Assistance services resulting from cases offorce majeure or the following events:
Civil or foreign wars, acknowledged political instability, popular movements, riots, acts of terrorism,
reprisals, restrictions to the free circulation of people and goods, strikes, explosions, natural catastrophes,
meltdown of atomic cores, nor delays in the execution of services resulting from the same causes.
What are the exclusions of the Assistance cover ?
We cannot intervene if your request for assistance is due to
Pollution, natural disasters,
Travel undertaken for the purpose of diagnosis and / or treatment,
States of pregnancy unless unforeseen complications, and in all cases from the 32 nd week ofpregnancy,
The result of a voluntary disregard for regulations in the visited country, or the practice of activities not
authorised by local authorities.
What are your obligations in the event of accident?
For all requests for assistance, you should contact us, 24 hours a day Mutuaide, medical@mutuaide.fr /00 33 (0)1.55.98.71.68 and obtain our prior approval before taking any steps or incurring any expenses.
When we have organized your transport or repatriation, you must hand over your initial travel tickets to us, as they will
have become the property of Mutuaide.

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5/ Legal liability
What do we cover ?
We cover the financial consequences of the legal liability you may incur during your private life, including during
traineeships/ internships with respect to, on the one hand, personal injury and/or damage to property and, on the other
hand, the consequential losses therefrom, caused accidentally to any person other than a person insured or a member ofyour family, that is your fault or the fault of things or animals under your care, this being provided up to the amount, andwith the deduction of an excess, indicated in the table of sums insured.
The cover also applies to objects entrusted during a period of traineeship/ internship up to the amount given in theschedule of cover, and with the deduction of an excess.
What do we exclude?
Besides the exclusions given under the heading “EXCLUDED RISKS FOR ALL BENEFITS”, we do not cover :1. damage intentionally caused or provoked by you,
2. damage resulting from the use of land motor vehicles, sailing and motor boats, and air navigation
appliances,
3. damage resulting from any professional activity,
4. objects entrusted to the insured (except in case of traineeships/ internships)
5. the consequences of any material damage and/or personal injury affecting you personally, andmembers of your family or any other person who is an insured party pursuant to the contract
herein,
6. consequential damage except where it is the direct result of accidental damage to property and/or
personal injury that is covered,
7. damage resulting from the practice of air sports or from hunting,
8. damage caused by buildings or parts of buildings owned, rented or occupied by the Member,
9. damage you caused due to a fire, explosion or flooding,
10. traineeships/ internships in the medical and paramedical field, except for traineeships/ internships
exclusively on an observation basis.
What are the limits of our cover ?
Settlement – acknowledgement of liability
You should not accept any acknowledgement of liability, nor any settlement, without our prior and written agreement.
However, simply acknowledging the materiality of certain facts is not considered to be an acknowledgement of liability,
nor is the fact of having procured emergency help for a victim when this is an act of assistance that anyone would have amoral duty to provide.
You should advise us within 5 working days of any event likely to incur your civil liability, unless there is an unforeseen
event or a case of force majeure; if this deadline is not adhered to and because of this we sustain a loss, then your cover
will lapse.
Proceedings
If legal action is taken against you, we will ensure your defense and will supervise the proceedings for the facts anddamage which come within the scope of the contract herein. However, you may join in the lawsuit as long as you canestablish a separate interest that is not taken charge of pursuant to the contract herein.
The mere fact of entering an appeal in your defense as a precaution may under no circumstances be interpreted in itself
as an acknowledgement of cover, and in no way implies that we agree to be liable for the harmful consequences of
events which would not be explicitly covered by the contract herein.
Even if you fail in your obligations after an accident, we are bound to compensate the people to whom you are liable.
Nevertheless, in these cases, we retain the right to take legal action against you for reimbursement of all the sums that
we have paid or provided on your behalf.

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Redress
Insofar as the means of obtaining redress are concerned:
We are entitled to act without reference to yourself before the civil, commercial or administrative jurisdictions, in
relation to the cover provided under this contract,
Before the criminal jurisdictions, redress may only be sought with your agreement,
if the lawsuit pending before a criminal jurisdiction no longer relates to any interests but civil interests, refusal to
give your agreement to our exercising the anticipated means of obtaining redress entails a right for us to claim
compensation from you equivalent to the loss which resulted for us.
Costs of proceedings
We will be liable for the costs of the proceedings, discharges and other settlement costs.
However, if you are ordered to pay a sum in excess of that of the cover, each of us shall bear these costs in proportion totheir respective share in the sentence.
What are your obligations in case of claim?
For any claim request, you must contact us at the following address: ACS, Claims Service, 153 rue de l'Université, 75007,
Paris, France / servicesinistres@acs-ami.com.

6/ Luggage
We only cover your luggage, objects and personal effects taken with you or bought during your journey, during travel(outward / return journey) up to the amount given in the schedule of cover, in the event of:- theft and loss,- total or partial destruction
The amount given in the schedule of cover constitutes the maximum reimbursement for all accidents occurring during theinsured period.
Our reimbursements are complimentary to those done by the Transport company.
What is excluded:
Besides the exclusions given under the heading « EXCLUDED RISKS FOR ALL BENEFITS», we cannot cover:
1. forgetting, loss (except by a Transport company), exchange,
2. the confiscation of property by the authorities (customs, police),
3. the fragile objects such as porcelain, glass, ivory, ceramic, marble objects,
4. the items listed hereinafter: jewels, device reproducing sound or image, documents recorded on tapes
or films as well as professional material, laptop computers, mobile phones, sport articles, musicalinstruments, food products, lighters, pens, cigarettes, alcohol, works of art, beauty products andphotographic films, any prosthesis, equipment of any kind, share certificates, eyeglasses, contactlenses, keys of any kind,
5. cash, and documents listed hereinafter: passport, identity card or residence card, car registration bookand driving license, credit cards, books, travel tickets,
6. luggage lost or damaged during journeys or intermediate journeys,
7. epidemics / pandemics.
How is your compensation calculated?
Compensation will be paid to you against documentary evidence and on the basis of like-for-like replacement value, lessobsolescence.
Under no circumstances is the proportional rule of capital provided in article L.121-5 of the French insurance code
applied.
What are your obligations in the event of a claim?
Our reimbursements being complimentary to those of the Transport company, your claim report must reach us within 5
working days, except fortuitous event or force majeure. If this deadline is not respected and therefore we suffer
prejudice, you lose all right to compensation.

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Your declaration of claim must be accompanied by:- The receipt of a complaint in the event of theft or theft declaration by a competent authority (police,
gendarmerie, transport company, board of trustees ...) when it comes to theft or loss by a Transport company;- The declaration of loss or destruction established with the carrier (maritime, air, rail, road) when your luggage orobjects were lost, were damaged or stolen during the period when they were in the legal custody of the carrier.
In case of non-presentation of these documents, you incur the forfeiture of your rights to compensation.
The sums insured cannot be considered as proof of the value of the property for which you are claiming
compensation, nor as proof of the existence of this property.
You are obliged, by any means in your power and by all documents in your possession, to provide evidenceof the existence and value of these goods at the time of the loss, and the extent of the damage.
If you knowingly use inaccurate documents or fraudulent means as proof, or if you make inaccurate statements or fail todisclose any relevant information, you will lose all rights to compensation, without prejudice to the prosecution that wewill then have grounds to instigate against you.
What happens if you recover all or part of the luggage, items and personal effects?
You must advise us immediately, in a letter sent by recorded delivery, as soon as you have been informed:
if we have not yet paid you your compensation, you must take back the luggage, items, or personal effects; weare then only obliged to pay for any damages or missing items;
if we have already paid out compensation, you have the option, within a period of 15 days, to do one of thefollowing:
1/ Either to abandon the said luggage, items or personal effects in our favor,
2/ or to take back the said luggage, items, or personal effects in return for restitution of thecompensation that you received, having, where appropriate, deducted, that part of the compensation
which corresponds to damaged or missing items.
If you have not made your choice within 15 days, we will deem that you are opting for abandonment.
What are your obligations in case of claim?
For any claim request, you must first contact us at the following address:
ACS, Service sinistres,
153 rue de l'Université, 75007, Paris, France,
Tél. 00 33 (0)1 40 47 91 04
servicesinistres@acs-ami.com.
to obtain our prior consent before taking any initiative or incurring any expense.

7/ Excluded risks for all benefits
Expenses are not reimbursed if consequent to the following events or situations:
1. expenses related to pre-existing conditions: consequent to accidents or illnesses which occurred prior
to enrolment,
2. an illness or an accident based on the intentional act of the covered person, self mutilation or attemptof suicide,
3. any intentional act that might lead to the application of the contract cover and any consequences ofcriminal proceedings that might be taken against the Insured
4. accidents or diseases incurred during sport competitions organised by any sports federation, as well as
the consequences of practice of the following sports: mountaineering, rock-climbing, bobsleigh,skeleton, any air sport, jet ski, martial arts, off-piste winter sports,
5. participation of the insured in duel, bet, crime and offence, fights (except self-defence), strikes,
6. use of non-prescribed medication, drugs or narcotics,
7. alcoholism or clearly state of drunkenness,

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8. accidents or diseases resulting directly or indirectly from the meltdown of an atomic core, or any
irradiation originating from ionizing radiation.
9. terrorism, sabotage, war (whether civil or not), riots, demonstrations, according to article L121-8 of
the French “Code des Assurances”,
10. activities when an insurer is banned from providing a contract or an insurance service due to a
sanction, restriction or prohibition provided by conventions, laws or regulations, including those
decided by the United Nations Security Council, the European Union Council or any other applicablenational law,
11. activities when they are subject to any sanction, restriction total or partial embargo or prohibition
provided by conventions, laws or regulations, including those decided by the United Nations Security
Council, the European Union Council or any other applicable national law. It is understood that thisprovision only applies in the case where the insurance contract or insured goods and/or activities
fall within the scope of the decision concerning the restrictive sanctions, total or partial embargo or
prohibition,
12. the absence of risk.

8/ Basis of the insurance contract
This policy is governed by the French Mutual Insurance Companies Code for the Medical Expenses, Repatriation
Assistance and Death Covers, and by the French Insurance Code for the Luggage loss, accidental Death & Disability
and Liability.
The definition of benefits, pricing and rules of implement concur with the laws regarding French social security, inforce on the effective date of the insurance contract.
Time stemming from the Insurance contract
The provisions relating to the time limit within which action stemming from the insurance contract may
be taken are set out by Articles L.221-11 of the French Mutual Insurance Companies Code and L.114-1
to L.114-3 of the French Insurance Code (Code des assurances), as reproduced below:
Article L 114-1 of the French Insurance Code:Any actions stemming from an insurance contract are time barred two years after the event from which the actions
stem.
However, this time limit only starts running:
1° In the event of reticence/concealment, omission, misrepresentation or inaccurate declaration of the risk incurred,from the date when the Insurer learned of the said risk;
2° In the event of an insurance loss, from the date when the interested parties learned of it, if they prove they were
unaware of it prior to that date.
When the action by the Insured Person against the Insurer is caused by recourse by a third party, the time limit foraction only starts running from the date when the third party takes legal action against the Insured Person or hasreceived compensation from the Insured Person. The time limit for action is increased to 10 years in life insurance
contracts when the beneficiary is a person distinct from the Contract holder and, in insurance contracts for personal
accidents, when the beneficiaries are the assigns of the deceased Insured Person.
For life assurance contracts, and notwithstanding the provisions of point 2° above, the right to action by thebeneficiary lapses at the latest 30 years after the death of the Insured Person.
Article L 114-2 of the French Insurance Code:The time limit for action may be interrupted by any of the ordinary causes for interruption thereof, and byappointment of appraisers after a loss. Interruption in the time limit for action may also result from a registered letterwith acknowledgement of receipt being sent by the Insurer to the Insured Person to obtain payment of the premium,and by the Insured Person to the Insurer to obtain payment of compensation.
Article L 114-3 of the French Insurance Code:Notwithstanding Article 2254 of the Code Civil (French Civil Code), the parties to the insurance contract may not, evenby mutual agreement, either change the length of the time limit for action, or add causes for suspension orinterruption thereof.
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Additional information:
The ordinary causes for interruption of the time limit for action indicated in Article L 114-2 of the French Insurance
Code and L.221-12 of the French Mutual Insurance Companies Code are set out in Articles 2240 to 2246 of the French
Civil Code, as reproduced hereafter. To learn of any potential updates of the aforementioned provisions, you may
consult the official website: "www.legifrance.gouv.fr".
Article 2240 of the French Civil Code:
Recognition by the obligee of the right of the person against whom the obligee could claim inaction within the time
limit interrupts the time limit for action.
Article 2241 of the French Civil Code:Instigating legal proceedings, even summary proceedings, interrupts the time limit for action and the time limit
beyond which rights lapse.
The same applies when the matter is brought before an incompetent jurisdiction, or when the deed of referral to thejurisdiction is cancelled through procedural irregularity.
Article 2242 of the French Civil Code:Interruption resulting from instigating legal proceedings is effective until the proceedings end.
Article 2243 of the French Civil Code:The interruption is null and void if the petitioner withdraws the petition or lets the proceedings lapse, or if the petition
is dismissed definitively.
Article 2244 of the French Civil Code:The time limit for action or the time limit after which rights lapse is also interrupted by protective measures being
taken pursuant to the French Code of Civil Enforcement Procedures (Code des procédures civiles d'exécution) or by an
enforcement being ordered.
Article 2245 of the French Civil Code:One of the jointly and severally liable obligees being summoned or notified through legal proceedings or through an
enforcement order, or recognition by the obligee of the right of the person against whom the obligee could claim
inaction within the time limit interrupts the time limit for action against all of the others, even against their heirs.
Conversely, one of the heirs of a jointly and severally liable obligee being summoned or notified, or that heir
recognising such a right does not interrupt the time limit for action with regard to the other co-heirs, even for
mortgaged debt, if the obligation is divisible. Such summons/notification or such recognition interrupts the time limit
for action with regard to the other co-obligees only for the share for which that heir is liable. In order to interrupt thetime limit for action for the entire obligation with regard to the other co-obligees, the summons or notification needs
to be made to all of the heirs of the deceased obligee, or all of the heirs need to recognise the right;
Article 2246 of the French Civil CodeSummons or notification made to the main obligee, or the main obligee recognising the right in question interrupts thetime limit for taking action against the guarantor.
Subrogation
The Insurer is subrogated to the rights and actions that the Insured may have against the Third Party responsible forthe loss, in the limit of the amount of compensation that the Insurer has paid. In case Subrogation could not operatein favour of the Insurer because of the Insured, the latter will be relieved of the obligations regarding the Insured in
respect of the Subrogation that would have been possible.
Overlapping Insurance
When several insurance contracts are taken out without fraud for the same risk, each of them is valid up to the limitsof the cover provided for under the contract. In this case, the Insured Person must inform all of the insurers.
Within these limits, the Insured Person may turn to the insurer of his choice. When they are contracted fraudulently,
the sanctions provided for by the French Insurance Code or by the French Mutual Insurance companies code
(invalidity of the contract plus damages) are applicable.

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Anti-money laundering
The controls that we are legally required to carry out as part of anti-money laundering and to combat the financing ofterrorism, especially cross-border flows, may lead us at any time to ask you for explanations or supporting documents,
including concerning the acquisition of insured goods.
Jurisdiction and applicable law
Pre-contractual and contractual relations are governed by French law and mainly the Insurance Code and the Mutual
Insurance Companies code.
Any litigation between the Insured Person and the Insurer concerning the conditions of applying this contract shall be
subject to French law and French courts shall have exclusive jurisdiction.
Nevertheless, if the Insured Person is domiciled in the Principality of Monaco, Monaco courts shall have solejurisdiction in case of litigation between the parties.
The language used in the context of pre-contractual and contractual relations is the French language.
Option of cancellation
You are asked to verify that you are not already covered by a contract covering one of the risks covered by the newcontract. If so, you have the right to cancel, throughout a cooling-off period of 14 full calendar days starting either asfrom the date of remotely signing/entering into the contract without fees or penalties if:-

you have taken out this contract for non-professional purposes;
this contract is in addition to the purchase of a good or service sold by a supplier;
you justify that you are already covered for one of the risks covered by this new contract;the contract you wish to cancel is not fully executed;
you have not declared any claim under this contract.

To exercise its right of withdrawal, the Insured must send a registered letter to ACS, 153, rue de l’Université, 75007,
Paris, France and can use the template below. In such case, the Insurer, through ACS, shall repay him/her in full thesum he/she has paid within 30 days from the date of receipt of his/her registered letter.
Example: “I, the undersigned, M (Name of the person concerned), residing at ..., withdraw frommembership to contract no..….taken out on the ... with …... I hereby certify that, on the date of sending
this letter, I have no knowledge of any claim under this contract since the contract was concluded. Dateand Signature ».
How is your compensation calculated for the assistance, legal liability and luggage benefits?
If the compensation cannot be determined by mutual agreement, it is assessed by means of an amicable assessment,
subject to our respective rights. Each of us chooses his expert. If these experts do not agree among themselves, theycall on a third and all three operate in common and by a majority of votes.
If one of us fails to appoint an expert or the two experts to agree on the choice of a third, the appointment is madeby the president of the high court, ruling in summary. Each of the co-contracting parties shall bear the costs and feesof its expert and, if applicable, half of those of the third.
How soon are you reimbursed?
Settlement occurs within 15 days from the agreement between us or from the notification of the enforceable judicial
decision.

9/ Data Protection
According to the Data Protection Act of January 6th 1978, as amended, and in the context of the management of theinsurance contract, the personal data of the Insured may be transferred to the Insurer, its administrators, its service
providers, its subcontractors or reinsurers. Insured persons are informed that treatments concerning them, as well as
those of their potential beneficiaries, are implemented as part of the execution, management and execution of thiscontract as well as for its commercial management. They may also be used in the context of control, prospecting, antiGLOBE PARTNER JP/01

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fraud and money laundering and terrorist financing operations, the search for beneficiaries of unregulated deathcontracts, the execution of legal and regulatory provisions. The data collected is necessary for the implementation ofthese treatments and is intended for the relevant services of the Insurer and its Managing Delegate and, whereappropriate, its subcontractors, service providers or partners. The Insurer is required to ensure that this data is accurate,complete and, if necessary, updated. The data collected will be kept for the duration of the contractual relationshipincreased legal requirements or in respect of the terms provided by the Commission Nationale Informatique et Libertés(CNIL).
This personal data may be transferred to service providers or subcontractors established in countries outside theEuropean Union. These transfers concern only countries recognized by the European Commission as having an adequatelevel of protection of personal data, or recipients with appropriate guarantees.
The Insured member has a right of access, rectification and erasure of his personal data, and when consent is necessary
for processing, he/she has the right to withdraw it. Under regulatory conditions, the Insured member has the right torequest the limitation of data processing, to oppose it, or request the portability of the data transmitted when it wasnecessary for the Contract or when its consent was required. The Insured also has the right to provide guidelines
regarding the processing of personal data after his/her death.
Any request for the exercise of his rights may be addressed to:
ACS,
To the attention of the Data Protection Officer,
153, rue de l’Université,
75007 Paris,
FranceEmail : dpo@acs-ami.com
Complaints relating to the collection or processing of your personal data may be addressed to the customer service
whose contact details are specified below. In the event of persistent disagreement concerning these data, the Insured
can refer to the CNIL: Commission Nationale Informatique et Libertés, 3 place of Fontenoy 75007 Paris, France, orwww.cnil.fr

10/ Mediation
What is the procedure for examining complaints?
The Insured’s usual contacts are able to study in depth all his/her requests and complaints. If, after this review, theanswers do not meet the Insured’s expectations, he/she can submit his/her claim to:
For ACS :ACS, Service réclamations,
153, rue de l’Université, 75007 Paris, France
E-mail: contact@acs-ami.com
For admission to insurance, settlement of premiums, claims.
Receipt of the complaint will be acknowledged within 10 days of its date of reception, unless the answer itself is given
to you within this time-frame. In any case, in accordance with applicable legislation, an answer will be given to you
within 2 months following the receipt of the complaint.
If no solution is found, the Insured can submit his/her claim to:

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For health, assistance - repatriation and death benefits (MGEN and MGEN Vie):VYV International Benefits – Service Relations Clientèle,
3/5/7 Square Max-Hymans 75748 Paris cedex 15, France
E-mail: clients@vyv-ib.com
If the disagreement remains, the Insured can submit his/her claim to the Ombudsman:
MGEN - Le Médiateur
3, square Max Hymans -75748 Paris Cedex 15, France
E-mail: mediation@mgen.fr
For the Luggage benefits, for the accidental death & disability benefits and the Civil Liability Cover:
Chubb European Group SE
Service Clients Assurances de Personnes
La Tour Carpe Diem
31, Place des Corolles, Esplanade Nord,92419 Courbevoie Cedex France
E-mail : gestionpartenariats@chubb.com
Chubb European Group SE adheres to the Mediation Charter of the Fédération Française de l’Assurance (French
Federation of Insurance). In the event of persistent and final disagreement, you have the option, after exhausting theinternal processing channels indicated above, of referring the matter to the Independent Mediator, whose postal
contact details are as follows: La Médiation de l’Assurance, TSA 50110 – 75441 PARIS CEDEX 09, France,
without prejudice to the other channels for legal action.
The Ombudsman’s opinion is not binding on the parties, who retain the right to apply to the competent court. The
Ombudsman is not entitled to decide on the conditions for admission to insurance.

11/Authority in charge of overseeing insurance companies
L’Autorité de Contrôle Prudentiel et de Résolution (ACPR) (the Prudential Oversight and Resolution
Authority) 4 place de Budapest CS 92459 75436 Paris Cedex 09, France.

12/ Consumer’s right to object to telephone marketing
If you do not wish to be contacted for the purposes of telephone marketing, you can have yourself added to a telephonemarketing opt-out list, free of charge. These provisions apply to any consumer, i.e. any natural person acting for
purposes unrelated to their commercial, industrial, craft or self-employed activities.

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13/ Schedule of cover
MEDICAL COSTS (1) - Maximum €150 000 / person / year (2)Surgery and hospitalization
100% of actual costs
In France: limited to 100% of FSS tariffs incontracted hospitals and to 80% of actual costs in
non-contracted hospitals
Consultations, pharmacy, x-ray analyses, paramedic care
100% of actual costs
In France: limited to 100 € per consultation
Emergency dental treatment
100% up to €300
Dental treatment following an accident
100% up to €600
DEATH, ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS
Death Benefit€1 000
Accidental death benefit€8 000
Permanent disability benefit further to an accident€30 000
LEGAL LIABILITY - Damage that has been caused to someone else during the trip (travel incl.) is guaranteed
Deductible€100 per file and per claim
Personal injury€4 500 000
Damage to property and consequential losses therefrom€450 000
Objects entrusted during a period of traineeship€11 500
ASSISTANCE BENEFITS
Medical transport
100% of actual costs
Repatriation
100% of actual costs
Presence of a relative if hospitalized for more than 7 days
Outward/return ticket + €80 per night (max. 8nights)
Early return following the death of a member of the
Outward/Return ticket
immediate family
Dispatch of essential medicines which cannot be found on
100% of actual costs
site
Forwarding of urgent messages
100% of actual costs
Search costs
100% up to €3 000
Advance of funds in cases of theft
up to €700
Legal assistance
up to €3 000
Advance of bail money
up to €7 000
Transport of body in cases of death
Actual costs (funeral costs limited to €1 500)
LUGGAGE INSURANCE
During the outward / return journey€1 150(1) If the insured person benefits from the French Social Security or any other insurance organism, ourreimbursements are complementary to the latter.
(2) for 12 months (one or several contracts)

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14/ Appendix: Medical claim form
Complete this form and join the original paid invoices, copies of the prescriptions and full medical report, copy of your passport(identification + arrival stamp). All these documents have to mention patient's full name, date of the medical treatment, name, address andtelephone number of the practitioner, medical facility, laboratory or pharmacist. Receipts not providing all this information won't be
sufficient (a detailed bill is required). Please, group your claims in order to avoid low amount reimbursements and take the precaution of
making photocopies of all the documents before sending them to:
A.C.S. – Medical Service – To the attention of the Medical Advisor 153 Rue de l'Université 75007 Paris, France
Claims requests of less than €500 can be sent by email to the attention of our Medical Adviser to: servicemedical@acs-ami.com
WARNING : The Company reserves itself the right to request the ORIGINAL documents at any time, within a period of 2 years.
Certificate ID: G_________________________ Date of birth: ______________________________________________
Family name: ______________________________________Given name: ___________________________________
Complete address: _______________________________________________________________________________
Telephone: ____________________________________Personal E-mail: _____________________________________________________The received treatment is related to:
Accident: Circumstances (date, place, details) ____________________________________________________________________________________________________________________________________________________________________________________(Example: throat infection on 9/12)
Illness/Diagnosis: Pathology and date: ___________________________________________________________________________________________________________________________________________________________________________________________
Medical or surgical history in direct or indirect relation to the medical condition concerned: ________________________________________________________________________________________________________________________________________________
Date of the first symptoms/signs: ______________________________________________________________________________
Detail of the invoices related to medical expenses:
Currency andDate of treatment
Country
settled amountTreatments

1. __________________________________________________________________________________________________

2. __________________________________________________________________________________________________

3. __________________________________________________________________________________________________

4. __________________________________________________________________________________________________

5. __________________________________________________________________________________________________

Comments: ________________________________________________________________________________________________________________________________________________________________________________________________________________
I would like to receive my reimbursement:
By wire transfer to a bank account in euros (please join IBAN and BIC codes).
By wire transfer to a bank account in another currency (please join official document with complete bank details and SWIFTcode) (Note: International transfers subject to variable bank charges and accepted for a minimum refund of €50)
By wire transfer to a third party bank account: please join a copy of the account holder’s passport and a written authorizationfrom the insured to receive the refund on a third party bank account.

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Annex : Privacy notice ACS
Protecting data and the privacy of insured members is a top priority. This privacy notice explains how and what type of
personal data will be collected, why it is collected and to whom it is shared or disclosed. Please read this notice carefully.
Processing of personal data
The information collected by ACS, insurance broker, simplified joint-stock company registered under number 317 218 188
RCS Paris, and located at 153, rue de l’Université – 75007 Paris, France, either directly from you or via your insuranceintermediary, is subject to data processing for the sole purpose of:••••preparing, concluding, managing and executing your quote or contract (study of needs, underwriting, calculationand collect of premium, preparation of endorsements, claims management, treatment of complaints if any…),
enforcing regulations related to anti-money laundering and terrorist financing prevention, fight against fraud,elaborating statistical and actuarial studies,
redistributing risks via reinsurance or coinsurance.

The processing of such data is carried out in compliance with the requirements applying to the collection, processing,recording, organization, purpose limitation and data minimization, storage, adaptation or alteration, retrieval,consultation, use, disclosure by transfer, dissemination, security of personal data.
The recipients of such data are, within the limits of their relevant assignments and according to applicable purposes, theinsurers, reinsurers, insurance intermediaries (your direct broker, if applicable), and eventually their subcontractors,
which intervene in the context of the execution or the management of your contract, third party administrators, themediator if a case is submitted to him/her, authorities legally authorized to manage your complaints, Tracfin for the fightagainst terrorism and anti-money laundering. Your data may also be transmitted to any person benefiting from thecontract (subscriber, insured, member, and beneficiary of the contract).
You expressly accept the collection and processing of data concerning your health. This information is necessary for the
execution and the management of your contract and your benefits, which is the sole purpose of the processing, andmade in accordance with the regulations of medical confidentiality. This information is exclusively intended for the
medical advisors of ACS, its departments in charge of managing your benefits, its third-party administrators andassistance providers if applicable, as well as for the insurers and reinsurers of your contract.
Transfer of personal data :In addition, we inform you that your personal data, or that of other parties concerned by or benefiting from the contract,
may be transferred outside the European Union if necessary for the performance of your contract.
The sole purpose of such transfers is to allow the performance of insurance and assistance claims, and only the datanecessary for the achievement of this purpose are transferred.
The recipients or categories of recipients authorized to receive the data are the accredited staff of the medical
administrators ans assistance companies as well as of the insurers, where appropriate.
These transfers are made according to the regulations relating to the protection of personal data applicable in theEuropean Union.
Your rights :In accordance with the French data protection law n° 78-17 of January 6 1978 as amended in 2004 and 2018 and to EU
regulation 2016/679 of April 27th 2016, you have the right to Access, Rectify, Erase, and to the Portability of, any data
concerning yourself, as well as the rights to the Restriction of and to Object to the processing of your personal data,
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which you can pursue by writing to our Data Protection Officer: dpo@acs-ami.com or by postal mail to « ACS, To theattention of the DPO, 153, rue de l’Université, 75007 Paris, France » (together with a copy of an official ID).
You may send a complaint:••

On the CNIL website by filling out the online form.
By postal mail writing to CNIL - 3 Place de Fontenoy - TSA 80715 - 75334 PARIS CEDEX 07 FRANCE

Regarding your health data, these rights may also be exercised by writing to the ACS Medical Consultant (ACS, To theattention of the Medical Consultant, 153, rue de l’Université, 75007 Paris, France) together with of a copy of an official
ID.
Data retention Duration :Personal data will be retained in accordance with applicable laws and regulations, and specifically as follows :Documents
Proposal, quotations
Individual Enrollment Forms
Contributions and premiums
Healthcare claims (illness/ accident medical
expenses)Claims files in the event of Death, Total andIrreversible Loss of Autonomy, Incapacity,
Disability

Data Retention Duration
3 years•
5 years from the date of the termination of contract(if no claim)•
5 years from the date of the termination of the insurance coverage
5 years
3 years from the date the claim is closed•••

Permanent Partial Disability Due to Illness(PPDI)- Permanent Partial Disability Due to
Accident Disability (PPDA)GLOBE PARTNER JP/01••

if the benefit has been paid: 10 years from the last date of payment
if the benefit has not been paid in totality or partially to thebeneficiary(ies) in the event of death of the Insured: 30 years from thedate of the recognition of the death of the Insured by the company
if the benefit could not be paid in total or partial due to the disappearanceof absence of the Insured: 30 years from the date of recognition by thecompany of the determination of the disappearance or absence of the
Insuredif the benefit has been paid: 10 years from the last date of payment
if not paid: 30 years

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MAJ20211216