TERMS AND CONDITIONS FOR INTERNATIONAL LONG-TERM …€¦ · l BDAE EXPAT GMBH l Kühnehöfe 3 l 22761 Hamburg Phone: +49-40-3 06874-0 l Fax: +49-40-3 06874-90 ... transport is to

l BDAE EXPAT GMBH lKühnehöfe 3 l 22761 Hamburg

Phone: +49-40-30 68 74-0 l Fax : +49-40-30 68 [email protected] l www.bdae.com

Registered office of the company: Hamburg l HRB 122052 l Local court of Hamburg l Managing Director: Philipp Belau

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1. INSURER: Würzburger Versicherungs-AG, Bahnhofstr. 11, D-97070 Würzburg2. POLICYHOLDER: BDAE EXPAT GmbH3. PARTIES ENTITLED TO BE

INSURED:Natural persons

4. INSURABLE PERSONS: Insurable are parties entitled to insurance who live outside the country whose nationality they hold as well as their

family members, if they are insurable according to the Terms and Conditions, Part I, Art. 1. Family members are

spouses living in the same household and children until the age of 18, if they are living in the same household and

the person entitled to insurance or their spouses are the legal guardian of those children. An application for a new

contract is required to reinstate insurance cover for children beyond the age of 18. Family members who possess

the nationality of the host country can also be insured. Persons can apply for this insurance up to the age of 67

years.5. CONTRACTUAL

FUNDAMENTALS:Terms and Conditions for International Health Insurances - Part I and Part II of Würzburger Versicherungs-AG

(EXPAT RETIRED). Please note that only the german version is legally binding.6. AREA OF APPLICATION: The insurance cover applies worldwide except for the native country and except for the USA / Canada / Germany.

Insurance cover is granted in the native country (except USA / Canada) for three months (accumulative) per insur-

ance year. If insurance cover is taken out for less than one year, the insurance cover provided in the native country

reduces proportionally.7. START OF INSURANCE

COVERAGE:At the time specified in the insurance confirmation document with consideration of the Terms and Conditions Part

I, Art. 4, but not before the stay abroad has begun.8. INSURANCE YEAR: From 1 April of each year respectively to 31 March of the following year.9. TERM OF THE INSURANCE

RELATIONSHIP:The duration of the insurance is unlimited under the terms and conditions of the group insurance contract.

11. INFORMATION ON THE STATEOF HEALTH:

In order to establish the state of health at the time of the conclusion of the contract, each person to be insured

must truthfully and completely fill in a health questionnaire. Persons of 60 years of age or over who are to be

insured must also submit on own expenses a health certificate issued by a doctor. The policy holder reserves the

right to conduct a risk check and decides whether the application is granted or denied. Please observe the exclu-

sion of benefits in the terms and conditions of insurance.

12. BENEFITS: EXPAT RETIRED BASIS EXPAT RETIRED TOP12.1 OUTPATIENT MEDICAL

TREATMENT:100% of the amount invoiced for medically necessary

outpatient treatment as a private patient, including radi-

ology, light therapy and other physical treatments, if pre-

scribed by a doctor, at reasonable and customary rates.

Not applicable.

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12.2 INPATIENT MEDICALTREATMENT:

100% for medically necessary inpatient treatment at a

hospital and treatment related accommodation for med-

ically necessary operations, X-rays, radiological treatment

and diagnostics. As a private patient in a 2-bed room

abroad; in a standard room with statutory basic treat-

ment in the native country (Please note the Terms and

Conditions Part I, Art. 5 paragraph 8). Notwithstanding

the Terms and Conditions Part I, Art. 6 paragraph 2b

medically nesessary rehabilitation following inpatient

treatment is covered.

Not applicable.

12.3 PHARMACEUTICAL PRODUCTS,BANDAGES AND REMEDIES:

100%, if prescribed by a doctor and medically necessary. Not applicable.

12.4 DENTAL TREATMENT: 100% of the invoiced amount for medically necessary

outpatient dental treatment. Inlays and onlays are not

covered. For each year of insurance cover a one-time

checkup is covered, but does not include any prophylac-

tic treatment.

Not applicable.

10. TERMINATION OF THEINSURANCE RELATIONSHIP:

The insurance cover within the insurance agreement can be terminated for individual insured persons with one

month notice to the end of the insurance year by the party entitled to insurance or the insured person in regard to

the policyholder.

TERMS AND CONDITIONS FOR INTERNATIONAL LONG-TERM HEALTH INSURANCES(PART II - WÜRZBURGER VERSICHERUNGS-AG)

EXPAT RETIRED

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PSYCHOTHERAPY: Not applicable. Not applicable.12.10

12.11 FOLLOW-UP LIABILITY: Not applicable. Not applicable.

The insurance premium shall be an annual contribution consisting of equal monthly instalments. It shall in each case

be due and payable in advance until the end of the insurance year.

DENTAL PROSTHESES/ORTHODONTIC MEASURES:

PREVENTIVE MEDICALCHECK-UPS:

Notwithstanding the terms and conditions of insurance

part I, Art. 6, paragraph 2q insurance cover continues for

newly occuring claims after the expiry of the waiting

period of 8 months for 80% of the costs for medically

necessary tooth replacement, to a maximum amount,

however:

- of 500 Euro per insurance year within the first three

years of the policy and

- 2,000 Euro in subsequent years.

The limits apply on a pro-rata basis for registration /

deregistration during the insurance year. Benefits of a

specific insurance year may not be transferred to other

insurance years.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

Not applicable.

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12.8 AIDS AND APPLIANCES:

12.6 Preventive outpatient medical examinations for early

detection of cancer in accordance with statutory pro-

grammes which have been introduced in Germany.

BENEFITS IN CONNECTIONWITH PREGNANCIES ANDDELIVERIES:

Notwithstanding the Terms and Conditions Part I, Art. 6,

paragraph 2g insurance cover continues for the follow-

ing aids, if medically necessary and prescribed by a doc-

tor:

a) Visual aids costing up to 50 Euro per person insured

and year of the policy,

b) bandages, dressings, orthopaedic inserts and walking

supports in simple design.

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12.9OTHER BENEFITS: a) 100% of the transport costs to the nearest suitable

hospital for inpatient treatment and for first-aid after

an accident to the nearest suitable doctor and back.

b) For medically necessary return transport or con-

veyance to the permanent place of residence of the

insured person, the insurance company will reimburse

- up to 5,000 Euro within a continent,

- up to 10,000 Euro between continents.

If for the return journey an authorised ambulance aero-

plane should be called for, the restriction to the benefit

amount no longer applies. The most economical means of

transport is to be selected for the return journey, so long

as this is possible from the medical point of view. Medical

necessity for a return journey is given, if sufficient medical

care is not available in the country of residence. To prove

the medical necessity of return transport, a certificate of

the doctor treating abroad must be submitted.

Not applicable.

13. QUALIFYING PERIODS: None 8 months for tooth replacement.14. MONTHLY INSURANCE

PREMIUM:205 Euro 65 Euro

The amounts indicated above shall be increased as from the first month of the insurance year during which the

Insured Person reaches the respective age.14.a DEDUCTIBLE: 250 Euro 0 Euro

The deductible applies to each insured person per insurance year. The deductible for insurance cover which is

required for less than one year is calculated proportionally.15. MISCELLANEOUS: Changing of modules or adding an additional module is not permitted. No pension reserve fund will be established.

You are recommended to take out a dormant insurance policy scheme.

up to 50 years

from 50 years

from 65 years

from 70 years

277 Euro

339 Euro

369 Euro

81.25 Euro

104 Euro

104 Euro

ART. 1 INSURABLE PERSONS AND ELIGIBILITY FORINSURANCE

So far as has not been agreed to the contrary, the following shall apply:

1. The application of insured persons in the framework insurance agreement canonly be submitted by the party entitled to insurance. Parties entitled to insur-ance are juridical and natural persons according to the respektive underlyingtariff conditions.

2. Natural persons may be insured.

3. Not insurable and despite premium payment not insured are

a) Persons who are in need of constant care. A person is in need of care if he/she for the most parts needs external help in order to manage the tasks ofdaily life.

b) Persons who are constantly excluded from participating in daily life. For thisclassification, in particular the mental state and the objectiv life circum-stances of the person must be considered.

4. No insurance cover is granted for insured persons, who are on a long termdomiciled in the Federal Republic of Germany.

5. Natural persons with a limited residence permit for the Federal Republic ofGermany may not be insured, if at the time of applying for registration in theframework insurance agreement the entire insurance duration of all healthinsurance agreements concluded during the visit exceed a period of 5 years.

ART. 2 CONCLUSION AND TERMINATION OF THE INSURANCECONTRACT

1. The framework insurance contract will be concluded between the insurancecompany and the policy holder for the duration of a year. The frameworkinsurance contract will be extended by one year if notice of termination is notgiven with a term of notice of three months to the expiry date.

2. The policyholder is obligated to inform the party entitled to insurance and theinsured persons of notice of termination of the framework insurance agree-ment with two months notice before the termination takes effect.

3. The legal regulations on the extraordinary right to give notice of terminationremain unaffected.

4. At termination of the framework insurance agreement, the insurance compa-ny will offer the insured persons continuation of the insurance cover.

5. The insurance cover within the insurance agreement can be terminated forindividual insured persons with one months notice to the end of the insuranceyear by the party entitled to insurance or the insured person in regard to thepolicyholder.

6. If the party entitled to insurance and the insured person are not identical, anotice of termination only becomes effective, if the insured person concernedby the termination has attained knowledge of the termination declaration. Thepolicyholder proves this accordingly to the insurance company at deregistra-tion from the framework insurance agreement. The insured person concernedis in this case entitled to continue the insurance contract under designation ofa future party entitled to insurance. An appropriate declaration must be madewith-in two months after receiving the notice of termination.

ART. 3 INSURANCE PREMIUMS, ADJUSTMENT OF BENEFITSINSURANCE YEAR

1. The premium is an annual premium, which is made out in equal monthly instal-ments. It becomes due for payment in advance by the time of the end of eachcontractual year.

2. The policyholder is entitled to deregister individual insured persons from the

framework insurance agreement because of non-payment of the premium.

3. Insurance company shall be entitled to make changes in the premium level orthe extent of the benefits at the beginning of a new insurance year, providedthat it notifies the policyholder of this with a term of notice of three monthsto the end of the agreed tariff insurance year.

4. The insurance year will be defined in the Terms and Conditions for long-termhealth insurances - Part II of Würzburger Versicherungs-AG.

5. The policyholder shall be obliged to give the party entitled to insurance and theinsured person written notice of an adjustment of the premium level or of thelevel of benefits paid within a term of two months to the end of the agreedtariff insurance year.

ART. 4 AREA OF APPLICATION, COMMENCEMENT AND TERMAND TERMINATION OF THE INSURANCE COVERAGE

The insurance company shall offer insurance cover to insured persons, who areresident for a limited time in the context of a limited visit to the agreed tariff areain the context of these conditions of insurance. So far as has not been agreed tothe contrary, the following shall apply:

1. The insurance cover starts for the insured person after binding registration intothe framework insurance agreement at the time (start of insurance) specifiedin the insurance confirmation document,

a) however not before start of the stay of the insured person in the agreed tar-iff area;

b) not before effectiveness of the insurability of the insured person accordingto tariff;

c) not before payment of the premium;

d) not before expiration of waiting periods agreed according to tariff.

2. No insurance cover is granted for claims occasioned before or at start of insur-ance.

3. No benefits will be paid for claims occasioned during the waiting period asagreed in the tariff.

4. The maximum duration of insurance cover for the insured person is defined interms of the relevant product.

5. Insurance cover for individual persons insured comes to an end, even in con-nection with pending claims, with

a) end of the insurance relationship of the insured person, at the latest how-ever upon expiration of the maximum duration of insurance of the selected tariff;

b) deregistration from the group of persons insured by the party entitled toinsurance, taking into account the terms of notice and conditions defined in the tariff;

c) death of the person insured;

d) at the end of the month following termination of the temporary visit of theinsured person in the agreed tariff area or final return of the insured per-son to their native country;

e) with the ending of the insurability of an insured person according to Termsand Conditions Part I, Art. 1;

f) as soon as the tariff terms on the insurability of an insured person are inap-plicable;

TERMS AND CONDITIONS FOR INTERNATIONAL LONG-TERM HEALTH INSURANCES(PART II - WÜRZBURGER VERSICHERUNGS-AG)




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g) with termination of the framework insurance agreement between theinsurance company and the policy holder.

ART. 5 SUBJECT MATTER OF INSURANCE COVERAGE ANDVOLUME OF INSURANCE BENEFITS

So far as has not been agreed to the contrary, the following shall apply:

1. The insurance cover results from the insurance confirmation, these conditionsof insurance, the selected products, statutory regulations of the FederalRepublic of Germany.

2. Grounds of a claim shall be the medically necessitated treatment of a personinsured on account of illness or in consequence of an accident. The claim shallbe considered to begin with the treatment, and shall end when medical findingsindicate that there is no further need of treatment. If the medical treatment mustbe extended to an illness or consequence of an accident, with no causal connec-tion to the previously treated condition, then this is considered a new claim.

3. In so far as the tariff defines the relevant benefits, further grounds for a claimshall also be:

a) Medically necessitated treatment including pregnancy examinations, preg-nancy treatments, in as far the pregnancy had not yet commenced at thebeginning of the insurance relationship of the insured personas well astreatment for miscarriage;

b) Medically necessitated pregnancy treatment due to acute complaintscaused by and treatment due to miscarriage as well as medically necessitat-ed abortions and deliveries up to the end of the 36th week of pregnancy(premature birth), even if the pregnancy had already commenced at thestart of the insurance relationship of the insured person, if the necessity fortreatment was not yet obvious at this time;

c) Deliveries after expiry of the waiting period according to the agreed tariff;

d) Outpatient examinations for early diagnosis of illnesses according to pro-grammes and introduced to the Federal Republic of Germany and pre-scribed by statute (purposeful preventive medical checkups);

e) Death.

4. The insurance company shall offer insurance cover for urgent and unexpectedinsured events occurring during the stay in the agreed tariff area.

5. The nature and amount of the insurance benefits shall be derived from theseconditions of insurance of the respectively selected tariff.

6. In the area of cover the insured person may choose from those medical doc-tors, dentists, licensed general practitioners specialised on alternative medicineand midwives who are practising on a legally approved basis in the insured’scountry of residence and who invoice on a locally customary basis or - if appli-cable - according to the official scale of charges for their profession.

7. Pharmaceuticals, bandages, medicines and medical aids must be prescribed bythe qualified practitioners mentioned in Terms and Conditions Part I, Art. 1,paragraph 6. Pharmaceuticals may also be obtained from a pharmacy.Nutriments, tonics, mineral water, disinfectants and cosmetics, mineral water,dietary, and baby food and the like are not considered pharmaceuticals even ifthey have been prescribed.

8. In case of medically necessitated hospital treatment, the person insured hasfree choice from among those public and private hospitals that are under con-stant medical supervision, possess sufficient diagnostic and therapeutic equip-ment and conduct case histories and do not provide health resort respectivelysanatorium treatments or accept convalescent patients. Insurance protection isgranted for the general class (multiple bedrooms) without coverage options(private treatment by doctor).

9. In case of medically necessitated hospital treatment in licensed hospitals,which also carry out health resort or sanatorium or convalescent treatmentsbut which in other respects conform to the Terms and Conditions Part I, Art.1, paragraph 8, benefits at the agreed rate will only be paid if the insurancecompany has given written consent to this before the start of the treatment.In case of a TB condition, benefit will be paid to the extent defined by the con-tract for hospital treatment in TB treatment centres and sanatoria as well.

10.The insurance company will pay benefit to the extent defined by the contractfor examination and treatment methods and pharmaceuticals that are gener-ally recognised by school medicine. It will in addition pay benefit for methodsand pharmaceuticals, which have proved themselves in practice to be equallylikely to achieve success; the insurance company may however reduce the levelof benefit to the amount that would have been paid if existing school medi-cine methods or pharmaceuticals had been used.

11.The insurance company will pay to the extent defined in the tariff the con-veyance and funeral costs, if the death of an insured person is the conse-quence of an insured event.

12.The insurance company carries additional costs to the extent defined in the tar-iff for a medically necessitated return transport prescribed by a doctor to thenearest suitable hospital in the native country or to the permanent place of res-idence of the insured person. Medical necessity for a return journey is given, ifit is proven that in the agreed tariff area sufficient medical treatment is notensured and the return journey is recommended by the doctor of the insurancecompany. The costs of an also insured accompanying person are assumed, inas far the accompaniment is medically necessitated, officially ordered orrequired by the accomplishing transport company.

ART. 6 GENERAL RESTRICTION OF INSURANCE BENEFITSSo far as has not been agreed to the contrary, the following shall apply:

1. Insurance cover is not granted for damage occasioned by active participationin strikes, war, war-like events, civil disturbance, damages by nuclear energy, aswell as for such events, resulting from intentional activities of the policyholder,the party entitled to insurance or the insured person.

2. There is no obligation to pay benefit:

a) On account of illnesses and complaints including their consequences exist-ing and known at start of the insurance cover. Furthermore, there is noinsurance cover for the consequences of such illnesses and accidents, whichhave been treated in the last six months before start of insurance.

b) For spa and sanatorium treatments as well as rehabilitation measuresorganised by party legally responsible for rehabilitation;

c) For treatments during a stay in a spa or a health resort, even if this involvesa stay in hospital. This limitation shall no longer apply if the person insuredhas his/her constant place of residence there or if he/she becomes unableto work as a result of a sickness independent of the purpose of his/her visitor as a result of an accident that has occurred there, so long as this results,on medical testimony, in his/her being unable to journey home. This limita-tion also shall no longer apply if and to the extent that the insurance com-pany has given written consent to benefit being paid before the start of res-idence abroad.

d) In consequence of an accommodation occasioned by the need of lingeringillness, care or custody;

e) For the treatment of mental or emotional disturbances, or for hypnosis, psy-choanalysis or psychotherapy;

f) For immunisation measures;

g) For medical aids;

h) For treatment of sterility, including in vitro fertilisation well as pertinent pre-liminary examinations and subsequent treatments;

i) For preventive medical examinations;

j) For treatments by spouses, parents, children or persons living together inthe immediate domestic circle or persons living together with the insuredperson within his/her own or guest family. Costs of materials will be reim-bursed in keeping with the given tariff.

k) For treatment on account of such illnesses, including their consequences, orconsequences of such accidents as are occasioned through professionalparticipation in sporting competitions organised by sporting federationsand associations or prenotory measures related to these, or such as arerecognised as war injuries and are not explicitly included in the insurancecover.

l) On account of withdrawal measures including courses of withdrawal treat-ment;

m) On account of such illnesses, including their consequences, which arise asa result of the person's having neglected to obtain the protective inocula-tions recommended by the World Health Organisation or prescribed bystatute, unless there should be medical reasons why protective inoculationcannot be carried out. In this case, the medical reasons are to be proved tothe insurance company by the submission of a doctor's certificate.

n) For treatment of a dependency syndrome and its consequences;

o) For attempted suicides and their consequences;

p) For organ donations and their consequences;

q) For tooth replacement (such as e.g. pivot teeth, insert fillings, crowns,implants) and orthodontic treatment, occlusive overlay aids and gnatholog-ic measures.

3. So far as has not been agreed to the contrary, there is no obligation to providebenefits for treatments by doctors, dentists, licensed general practitioner spe-

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cialised on alternative medicine, hospitals or midwives whose invoices theinsurance company has excluded from reimbursement on good grounds.Precondition for this is that the insurance company has notified the party enti-tled to insurance and the insured person before occurrence of the insuredevent and of the practitioner who will not be reimbursed. In so far as at thetime of notification a claim should be pending, no obligation to pay benefit forthe practitioner concerned shall exist for expenses incurred after the expiry ofthree months from the time of notification being given.

4. If the medical treatment or other measure for which benefit has been agreedupon should exceed the medically necessitated limits, or if the remunerationclaimed is out of proportion, the insurance company may reduce benefit to anacceptable level.

ART. 7 OBLIGATIONS AND CONSEQUENCES OF THEIRINFRINGEMENT

1. Policyholder, parties entitled to insurance and insured person are obligated,after occurrence of the insured event

a) To avoid everything that could lead to an unnecessitated increase in costs;

b) To immediately notify the insurance company or its agent of all damagesthat could presumably exceed a sum of 1,000 Euro;

c) To permit the insurance company or its agent to make all reasonable exam-inations regarding the cause and amount of its duty to pay benefits, pro-vide all relevant information in this connection, to submit original docu-ments, and submit a death certificate in the case of death.

2. The insurance company is to be notified of any hospital treatment within tendays from its starting.

3. The person insured must submit the relevant documentary evidence to theinsurance company within three months from the time of each individualcourse of treatment.

4. If a person insured has concluded a contract for the insurance of medicalexpenses with another insurance company, if such exists or a person insuredavails himself/herself of the entitlement to insurance in connection with statu-tory health insurance cover, the party entitled to insurance or the personinsured shall be obliged to notify the insurance company without delay of theother insurance cover arranged.

5. The insurance company is to be informed of a case of pregnancy within fourweeks after the existence of a pregnancy has been established, unless definedotherwise in terms of the relevant tariff.

6. The insurance company is to be informed of medically necessitated returntransports before being carried out.

7. If required by the insurance company, the insured person is obligated to beexamined by a doctor assigned by the insurance company.

8. Start and end, as well as an interruption of a stay in the area according to tar-iff, as well as the presence of the tariff terms concerning insurability must beproved by the insured person on request of the insured company in the caseof benefit.

9. The party entitled to insurance and the person insured are obligated to imme-diately communicate changes of address to the policyholder.

10. If the policy holder, the party entitled to insurance or the person insured wil-fully infringes one of the contractually agreed obligations, the insurance com-pany shall be released from its obligation to pay benefits. In the case of a gross-ly negligent infringement of the obligation, the insurance company is entitledto reduce the benefits by an amount commensurate with the seriousness ofthe fault of the policyholder, the party entitled to insurance or the personinsured. The onus of proving that there has been no gross negligence restswith the policyholder, the party entitled to insurance or the person insured.

ART. 8 PAYMENT OF INSURANCE BENEFITSSo far as has not been agreed to the contrary, the following shall apply:

1. The insurance company shall be obliged to pay out benefits only if the follow-ing documentary proof is supplied, which then become the property of theinsurance company:

a) Paid original receipts, which must carry the first name, surname and dateof birth of the person treated, name and address of the doctor treating thepatient, the description of the illness, nature of the services provided by thetreating doctor according to type, place and treatment period. If compen-sation may be claimed under another insurance contract in connection withan insured event and if the claim has first been asserted for the other con-tract, then duplicates of the invoices will be considered sufficient, providedthat the other insurance company has made a note on the document of thebenefit paid. The insurer may request translation into German or English, ifthe original receipts or documents relevant for compensation are submitted

in a foreign language.

b) Prescriptions must be presented together with the doctor's bill, the bill forpharmaceuticals and medical aids together with the prescription.

c) Proof of the amount of costs, which would have ensued in the case of aregular return journey, if benefits are asserted for a medically necessitated return transport. Furthermore, a doctor's certificate, which should clearlydemonstrate the medical necessity of return transport, must be submitted.

d) For the assertion of claims in connection with conveyance of the body orfuneral costs an official death certificate and medical certificate giving the cause of death must additionally be submitted.

2. Costs that have been incurred in a foreign currency will be converted into thecurrency valid in Germany at the exchange rate of the day on which thereceipts are received by the insurance company, unless the foreign currencyrequired for payment of the invoice was acquired at a less favourable rate andthat this was caused by a change in the currency valuation.

3. Costs incurred for the payment of insurance benefit by banker's draft to a for-eign country, or for special forms of fund transfer which have been agreed on,will be deducted from the benefit paid.

4. Claims to insurance benefit can neither be assigned nor given in pledge.

5. In connection with examining the benefits to be provided, it may be necessi-tated for the insurance company to obtain personal-related health data with-in the legally permitted scope. If the party entitled to insurance or insured per-son fail to consent to this and the examination of benefits is not made possi-ble in other ways, and if the insurance company as a result, is unable finally todetermine the amount and scope of its obligation to provide benefits, the be-nefits are not payable.

6. One month after notification of a claim, the minimum amount which ispayable as matters then stand may be claimed as a payment on account. Thesaid period stops running as long as the insurance company’s examination ofthe claim is hindered by fault on the part of the policyholder, the party entitledto insurance, the insured person.

7. Claims under this framework insurance agreement shall become time-barredafter three years. The limitation period begins at the end of the year in whichthe benefit may be demanded.

ART. 9 COMPENSATION FROM OTHER INSURANCE CONTRACTSAND CLAIMS AGAINST THIRD PARTIES

1. If compensation may be claimed under another insurance contract in aninsured case, the other contract shall take precedence over this contract. Thisapplies likewise, even if a subordinate liability has also been agreed upon inone of these insurance contracts, irrespective of when the other insurance con-tract was concluded. If the insured event was first communicated to the insur-ance company via this framework insurance agreement, the insurance compa-ny will pay in advance and will contact the other insurance company directlyconcerning distribution of costs.

2. Claims of the policyholder, the party entitled to insurance or the insured per-son against third parties pass to the insurance company to the statutory extent,as far as the insurance company has reimbursed the damage. If necessary, thepolicyholder, the party entitled to insurance or the insured person is obligatedto provide a statement of assignment to the insurance company. The insurancecompany’s obligation to provide benefits is suspended until the statement ofassignment has been submitted.

3. Claims of the policyholder, the party entitled to insurance or the insured per-son against a medical practitioners due to excessive fees pass to the insurancecompany to the statutory extent, if the insurance company has reimbursed theappropriate bills. If necessary, the policyholder, the party entitled to insuranceor the insured person are obligated to assist during assertion of claims.Furthermore, the policyholder, the party entitled to insurance or the insuredperson are obligated, if necessary, to provide a declaration of assignment tothe insurance company. The insurance company’s obligation to provide bene-fits is suspended until the declaration of assignment has been submitted.

ART. 10 SETOFFPolicyholder, the party entitled to insurance or the insured person is only entitledto a set-off against claims of the insurance company in the case of undisputed orfinally asserted counterclaims.

ART. 11 DECLARATIONS OF INTENT AND NOTICES Declarations of intention and notifications to the insurance company require thewritten form (Letter, fax, e-mail, electronic data medium, etc.). The person insuredhas an intrinsic right to assert claims based on the contract against the insurancecompany.

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ART. 12 APPLICABLE LAW / CONTRACT LANGUAGEGerman law shall apply unless international law takes precedence. The languageof the agreement is German. Please note that only the german version is legallybinding.

ART. 13 PROFIT PARTICIPATIONThe insurance specified here is not entitled to surplus.

ART. 14 SUPERVISORY AUTHORITY AND COMPLAINTS OFFICEIf you should not be satisfied with a benefit or a decision of the insurance com-pany, please contact the respective insurance company directly.

The responsible supervisory authority for complaints is the Bundesaufsichtsamt fürFinanzdienstleistungen, Graurheindorfer Straße 108, 53117 Bonn.

The Würzburger Versicherungs-AG is member of the PKV-Ombudsmann. This enti-tles persons insured in tariffs covered by the Würzburger Versicherungs-AG toaddress the independent and neutral Ombudsman, if they do not agree with adecision made. The procedure is free of charge.

Ombudsmann Private Kranken- und Pflegeversicherung

Postfach 06022210052 Berlin

Tel.: 0800 2 55 04 44Fax: 030 20 45 89 31

www.pkv-ombudsmann.de

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BDAE Expat GmbH Kühnehöfe 3 • 22761 Hamburg • Germany

Registered office of the Company: Hamburg • HRB 122052 Local court of Hamburg • Managing Director: Philipp Belau

Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90

E-mail: [email protected] Web: www.bdae.com

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1. Right of RevocationYou may revoke your contract declaration in text format within a term of 14 days without being obliged to indicate the reasons therefore (e.g. by letter, fax message, e-mail). Said term shall commence upon your receipt in text format of the confirmation of cover, the contractual provisions inclusive of the General and Special Insurance Terms and Conditions, the other information according to Section 7 paragraphs 1 and 2 of the German Insurance Contract Act (VVG) in conjunction with Sections 1 through 4 of the VVG-Decree on Information Duties and this information on your right of revocation.

For observing the revocation period, the revocation must have been dispatched in due time. The revocation shall be addres-sed to:

BDAE Expat GmbH, Kühnehöfe 3, 22761 Hamburg, Fax: +49-40-30 68 74-90, E-mail: [email protected]

2. Consequences of a RevocationIn the event of an effective revocation, insurance coverage shall cease to exist and all amounts paid by you within the fra-mework of the contractual relationship shall be reimbursed to their full extent. The reimbursement of refundable amounts shall take place immediately and in no case later than 30 days after receipt of the revocation. If insurance coverage does not commence prior to the expiry of the revocation period, an effective revocation shall result in the obligation to refund any payments and surrender any benefits (e.g. interest) received.

3. AttentionThe right of revocation shall lapse upon your explicit request if the contract has been completely fulfilled both by you and by us prior to your exercise of the right of revocatio.

End of Instructions on the Right of Revocation

RIGHT OF REVOCATION

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Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90


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What is Insured?

The insurance policy shall become applicable whenever phy-sicians or medical staff have committed treatment errors causing harm to you in any manner. True, the relationship between physicians and patients is based on confidence. Nevertheless, also medical professionals may make mis-takes. In such events, it is often particularly difficult for pa-tients to get justice when involved in a complicated conflict about treatment errors. This is all the more true because patients will in such events usually be forced to hold discus-sion with the professional liability insurance of the medical professional rather than with the treating physician himself or herself.

� Legal disputes up to one million Euros each shall be covered on a worldwide basis. Up to this amount, ARAG shall assume all lawyer’s and legal costs.

� Upon request, the insurer shall also recommend a law-yer specialised in medical law.

� Access to the ARAG online legal service providing approx. 1,000 legally verified sample letters and docu-ments from various fields of law.

� Within the framework of ARAG-JuraTel®, lawyers will be available for an initial consultation by phone in order to help you in case of claims for damages or in the event of an alleged criminal offence.

� Once per calendar year, you will be able to consult a law-yer accredited in Germany in order to prepare or amend an advance health care directive inclusive of an enduring power of attorney; in this context, an amount of up to EUR 250 shall be covered.

Which Errors are deemed to be Medical Treatment or Advice Errors?It is not only the much-cited pair of scissors forgotten in the abdomen during a surgical intervention that must be regarded as treatment error. To give only one example, such errors also include a faulty advice on the dosage of a medicine. Hence, an inappropriate, particularly a careless, improper or delayed treatment of a patient by a physician shall be regarded as treatment error. If a physician has failed to inform a patient about the necessities and risks of a treatment, such failure shall be regarded as medical ad-vice error – also covered by this insurance. All this shall not only apply to physicians, but also to hospital staff, psycho-therapists, pharmacists or nursing services. With respect to the patient legal expenses insurance, all these persons have the same status as physicians.

In addition to your overseas health insurance, BDAE has concluded for you a patient legal ex-penses insurance for foreign countries without charge. Said insurance shall provide protection against medical treatment and medical advice errors. Thanks to the cooperation between BDAE and ARAG, said patient legal expenses coverage shall be available for you on a worldwide basis.

About ARAG

ARAG is the largest family-owned company in the German insurance sector and considers itself as versatile quality insurer. Apart from its focus on legal expenses insurances, it also provides its customers in Germany with attractive need-based products and services under one roof in the fields of composite services, health and prevention. Operating in a total of 17 countries, inclusive of the USA and Canada, and offering a range of legal expenses insurances and legal services, ARAG furthermore holds a leading position in many international markets via its international branches, companies and shareholdings or interests. With its more than 4,000 employees, the group generates sales and premiums in a volume of more than EUR 1.6 billion.BDAE has been cooperating with the company since 2008. ARAG and BDAE have jointly developed the first legal expens-es insurance for overseas stays that applies on a worldwide basis.

Supplementary Service:

PATIENT LEGAL EXPENSES INSURANCE FOR BDAE CLIENTS

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BDAE Holding GmbH Kühnehöfe 3 • 22761 Hamburg • Germany


Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90


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� Organisation of emergency evacuations as well as transfers to other suitable hospitals in medically necessary cases

� Organisation and implementation of repatriations up to EUR 250,000 per insured event

� Implementation and assumption of costs for trans-fers in case of death up to EUR 10,000

Supplementary Service:MEDICAL ASSISTANCE FOR BDAE CLIENTS AND MEMBERS

Whoever is in need of medical care while staying abroad attaches importance to a rapid, qualified and seamless assistance. For this reason, the BDAE Group has integrated an Assistance Pro-gramme including the corresponding assistance, emergency and service offers in its insurance concept. The following assistance services shall be made available by BDAE to its insured persons and members in cooperation with the specialist Allianz Global Assistance:

� Multi-language, qualified 24 hour emergency hotline

� Worldwide network of medical service providers

� Information on dental/medical insurers (e.g. names, addresses and phone numbers as well as consulting hours of physicians, dentists, hospitals and clinics within the actual region of stay)

� Patient advice in routine and emergency cases

� Assistance when fixing treatment dates with hospitals and physicians for outpatient treatments

� Organisation of the admission to a hospital in case of illness

� Help and support of relatives by providing coun-try-specific data and information on health care services

� Information transmission between primary physi-cian and hospital as well as message transfer service

� Assistance with respect to the procurement and dis-patch of prescription medicines (to the legally permis-sible extent)

� Organisation of interpreting and translation services

� Wordwide Access to medical information in German and English

� Consulting and assistance in case of loss of important documents and means of payment

24/7 Emergency Preparedness of the BDAE under

+49-40-30 68 74-74

In addition to the assistance services mentioned on the left, BDAE shall upon request pay the costs for further services in connection of which the Allianz Global Assistance seeks authorisation directly from the BDAE and its risk carrier (insurer). These services include:

These services may be requested by person insured with the BDAE and BDAE members 24 hours a day and on 365 days a year. In order to guarantee a smooth operation, please ensure that you have your BDAE insurance number or your membership number ready when contacting Allianz Global Assistance.

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Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90


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In order to provide for a smooth processing of your insurance application, we kindly ask you to observe and check the following points:

One more recommendation: If we have any further questions with respect to the information to be rendered by you we kind-ly ask you to answer them within the terms set forth by us so that your insurance coverage can commence on the desired date.

Thank you very much for your cooperation!

IMPORTANT INFORMATION FOR FILING APPLICATIONS

All information has been given completely and in block letters.

The instructions on legal rights have been signed.

The consent to the collection and use of health data has been signed.

The signatures of the applicant as well as of all persons of legal age to be insured have been made.

All information on payment modalities has been given and all required signatures have been made.

The health certificate has been drawn up in a clearly legible manner in the German or English language and all nec-essary signatures of the examining physicians have been made.

Each individual question has been answered.

Questions answered with “yes” or questions indicating a diagnostic finding have been explained in more detail.

For the supplementary modules EXPAT GERMANY PLUS, EXPAT RETIRED TOP or for conclusions of EXPAT RESIDENT a dental status has been prepared.

The name and the complete address of the treating primary physician have been indicated.

For the case that inpatient treatments (hospital stays) have taken place, the findings report and the discharge re-port have been attached to the application.

Completion of Application Documents

Completion of the Health Certificate

With respect to the insurance products EXPAT GERMANY, EXPAT PRIVATE Premium, EXPAT INFINITY as well as EXPAT RESIDENT and EXPAT RETIRED, please note as follows:

� EXPAT GERMANY: In the event that the person to be insured has, upon commencement of insurance coverage, already stayed in Germany for a period of more than 31 days, a health certificate or evidence supporting a German prior insurance must be submitted. At the time of application, the health certificate must not be older than 14 days.

� EXPAT PRIVATE Premium: Information on the state of health must be submitted together with the application. As from an age of 50 years, a health certificate that must not be older than three months at the time of application is to be filed.

� EXPAT INFINITY, EXPAT RESIDENT und EXPAT RETIRED: Information on the state of health must be submitted together with the application. As from an age of 60 years, a health certificate that must not be older than three months at the time of application is to be filed.

Stand: 21.10.2019




Place, date:

HEALTH INSURANCE FOR PERSONS LIVING ABROAD

APPLICANT / PARTY ENTITLED TO INSURANCE:

Surname: First name(s): Current occupation:

BDAE membership no., if existing:

Address:

Phone: Fax: e-mail:PAYMENT DETAILS:

Payment type*:

Credit Card (+6%)*: oMaster-/Eurocard oVisa oDiners Valid until: Card no.:

Account / Card holder, if not applicant (please also sign below):INFORMATION ON ADDITIONAL HEALTH INSURANCE:

Do you have additional health insurance*? Insurance no.:THE FOLLOWING PERSONS ARE TO BE INCLUDED IN THE INSURANCE: (Please consider applicant)

Surname,

First name(s) Nationality

Sex*

m f

Date

of birth

Type of tariff*

EXPAT RETIRED Planned country

of residencei

Monthly

premium

(EUR)

Start of

insurance

(Month / Year)TOPBASIS

BIC / SWIFT-Code:Bank: IBAN:

Signatures:

(applicant or legal guardian of persons who are to be included in the insurance and all adults to be insured and

possibly different account holder / card owner)

oannually oevery six months (+2%) oquarterly (+3%) omonthly (+5%)

oNo oYes, with:

(*please tick)

I / we hereby apply for insurance cover as outlined by the terms and conditions for limited health insurance and sickness daily allowance cover of the EXPAT-series for

long-term journeys Part I and Part II (EXPAT RETIRED) for the persons listed above by registering them with the insurer as insured persons.

The total premium must be paid in advance in accordance with the chosen payment method. I hereby give authorization to BDAE Holding GmbH to debit the premi-

ums from my account or credit card (see above). As service provider of the BDAE Expat GmbH the BDAE Holding GmbH is authorized to administer its contracts to the

full extend and to collect debts. The debit will be assignable by the Creditor Identifier DE23ZZZ00000131378. The individual mandate reference will be disclose on the

Confirmation of Insurance Coverage. I hereby authorize my bank to redeem the debit notes presented by BDAE Holding GmbH for the benefit of the insurer. Note: the

premium is due after confirmation of insurance cover has been received and no later than the beginning of the insurance. I / we am / are aware that the policy holder

will not register the listed persons as insured persons with the insurer or will terminate their registration if the premium or other charges have not been paid in full due

to the actions of parties entitled to insurance. I / we am / are also aware that we do not have insurance cover in this case.

Insurer: Würzburger Versicherungs-AG

Policy holder: BDAE EXPAT GmbH

APPLICATION EXPAT RETIRED



Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90


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SEPA DIRECT DEBIT MANDATE

I hereby authorise BDAE Holding GmbH, in turn authorised by BDAE Expat GmbH for contract management and collec-tion, to collect payments owed by me from my account by means of direct debiting.

At the same time, I instruct my financial institution to honour direct debits drawn by BDAE Holding GmbH for the insurer.

Collection shall be identifiable on the basis of the Creditor Identifier DE23ZZZ00000131378 and the personal manda-te reference number shown in the confirmation of cover. Depending on the chosen payment method, collection shall take place on the 1st day of each month.

Please note: I shall be entitled to request the refund of the debited amount within a term of eight weeks commencing on the date of debiting. In this context, the terms and condi-tions agreed upon with my financial institution shall apply.

In the event that the funds on my account are insufficient, the financial institution in charge of my account shall not be obliged to honour the direct debit. Partial payments shall be excluded from direct debiting procedures.

In addition, the following regulations shall apply:

• Depending on the payment method elected below, the total amount shall be paid in advance in each case.

The person owing the premiums shall, towards the policyholder, be the person entitled to be insured and, towards the insurer, the policyholder.

• The premium shall be due for payment after receipt of the confirmation of cover, but in no case later than as to the inception date. I am aware that the policyholder will refrain from registering or will deregister the aforemen-tioned persons as insured persons with the insurer if the amount to be paid, inclusive of ancillary costs, fails to be paid or to be paid completely for reasons the person entitled to be insured is to be made responsible for. I am aware that no insurance coverage shall exist in such case.

• In the event that the person paying the premium is not identical with the person entitled to be insured / the insured person, the person entitled to be insured / the in-sured person shall be obliged to give the premium-paying person notice of the rendered information.

• Advance information on the collection of the owed amounts shall be given in the confirmation of cover addressed to the person entitled to be insured. In this context, the premium amounts, the due dates, the Credi-tor Identifier and the mandate reference number shall be indicated.

Applicable to premiums as from (dd/mm/yyyy)

Information on the person paying the premium

Surname Sex m f

First name(s)

Complete Address

Phone

IBAN

BIC/SWIFT Bank

Payment method annually twice a year (+ 2 %) quarterly (+ 3 %) monthly (+ 5 %)

Information on the insured person

Surname (if different from the person pay-ing the premium)

Sex m f

First name(s) (if dif-ferent from the person paying the premium)

Date of birth (dd/mm/yyyy)

Insurance number(s) (if available)

Place, date Signature of Account Holder




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HEALTH INSURANCE FOR PERSONS LIVING ABROAD

(*please tick)

With our signature we confirm that we have read and understood the following limitation:

No insurance cover is granted for temporary stays in the native country that last longer than three months per insurance year. This also applies if the three-month limit

is exceeded due to unexpected illness. (Exception: family members who are included in this insurance and who are nationals of the country of residence also have insur-

ance cover at home).

My / our insurance broker has advised me not to cancel existing insurances which apply at home or to join the public health scheme of your home country or - if pos-

sible - to apply for additional insurance cover.

Place, date

Insurer: Würzburger Versicherungs-AG

Policy holder: BDAE EXPAT GmbH


Surname: First name(s): Current occupation:THE FOLLOWING PERSONS ARE TO BE INCLUDED IN THE INSURANCE: (Please consider the applicant!)

Surname,

First name(s)

Nationality

m f

Date of birth

Commencement

of insurance

(Month / Year)

Signatures:

(applicant or legal guardian of persons who are to be included in the insurance and all

adults to be insured)

Sex*

ADDITIONAL DECLARATIONFOR THE EXPAT RETIRED APPLICATION

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Phone: +49-40-30 68 74-0 Fax: +49-40-30 68 74-90


WÜRZBURGER VERSICHERUNGS-AGLegal Instructions

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by Würzburger Versicherungs-AG (Insurer) as per Section 19 Paragraph 5 Sentence 1 of the German Contract Insurance Act (VVG)

LEGAL INSTRUCTIONS

Information as per Section 19 paragraph 5 of the German Contract Insurance Act (VVG) about the Consequences of an Infringement of Statutory Reporting Duties

In order to enable the Insurer to properly review your application, you are requi-red to give true and complete answers to the questions asked in the application documents. Circumstances considered by the applicant as being of little import-ance must also be reported. Any information you do not want to render to the insurance broker is to be directly reported in writing to the Insurer without any delay. Please note that you put your insurance cover at risk whenever you render incorrect or incomplete information. For more details on the consequences of an infringement of reporting duties, reference is made to the following information.

Are there Pre-Contractual Reporting Duties?

Until the time of submitting your contract declaration, you shall be obliged to give the Insurer correct and complete notice of any and all risk-relevant circums-tances known to you and requested by the Insurer in text format. Risk-relevant circumstances are circumstances having significance for the Insurer’s decision to conclude the contract with the contents agreed upon. Risk-related circumstances requested by the Insurer after your contract declaration, but prior to contract acceptance by the Insurer must also be reported.

What are the Possible Consequences of an Infringement of the Pre-Contractual Reporting Duty?

1. Rescission of Contract and Loss of Insurance Cover

In the event that you and/or the person to be insured fails to comply with the pre-contractual reporting duty, the Insurer shall be entitled to rescind the contract, unless you are able to provide evidence that you did not infringe the reporting duty with intention or with gross negligence. In the event of a grossly negligent infringement of the reporting duty, the Insurer shall not be permitted to rescind the contract if the contract would also have been concluded by the latter, even if under different terms and conditions, had the Insurer been aware of the undisclosed circumstances. In the event of a rescission, insurance coverage shall cease to exist. If the Insurer rescinds the contract after occurrence of an insured event, the Insurer shall continue to be obliged to pay compensation if you are able to provide evidence that the circumstance that failed to be reported or to be correctly reported by you has neither been the cause for the occurrence or determination of the insured event nor for the determination or volume of the duty to indemnify. The Insu-rer’s duty to indemnify shall, however, cease to exist if the reporting duty has been violated by you with fraudulent intent. In the event of a rescission due to an infringement of the reporting duty, the Insurer shall be entitled to receive insurance premiums until the rescission becomes effective.

2. Cancellation

In the event that the Insurer is not permitted to rescind the contract due to the absence of intention or gross negligence on your part when you failed to comply with your reporting duty, the Insurer shall be entitled to terminate the contract by observing a notice period of one month. The Insurer’s right to terminate shall be excluded if the contract would also have been concluded by the latter, even under different terms and conditions, had it been aware of the undisclosed circumstances.

3. Amendment of Contract

If the Insurer is not permitted to rescind or terminate the contract because it would have had concluded the contract also in knowledge of the undisclo-sed risks, even if under different terms and conditions, the other terms and conditions shall upon the Insurer’s request retroactively become a part of the contract if you negligently violated the reporting duty. If the premium is, due to the contract amendment, increased by more than 10% or the Insurer

excludes the coverage of the risk related to the undisclosed circumstance you shall be entitled to terminate the contract with immediate effect within one month after having received the respective notice of the Insurer about the contract amendment. The Insurer shall draw your attention on this right in its notification.

4. Execution of the Rights of the Insurer (Section 21 of the German Insurance Contract Act (VVG))

The Insurer shall be entitled to assert its rights of rescission, cancellation or contract amendment in writing within a term of one month. Said term shall commence on the date on which the Insurer becomes aware of the infringement of the reporting duty underlying the right asserted by it. When executing its rights, the Insurer shall indicate the circumstances relied on in this context. As long as the time period according to sentence 1 has not yet expired, the Insurer may in support of its decision also indicate additional circumstances at a later time. The Insurer shall not be permitted to rely on the rights of rescission, cancellation or contract amendment if it was aware of the undisclosed risk or the incorrectness of the reported information. Its rights of rescission, cancellation or contract amendment shall terminate upon expiry of three years after contract conclusion. This shall not apply to insured events occurred prior to the expiry of said time period. In the event that you infringed the reporting duty intentionally or fraudulently, the period shall be extended to ten years.

5. Fraudulent Misrepresentation (Section 22 of the German Insurance Contract Act (VVG))

The Insurer’s right to contest the contract on the grounds of fraudulent misre-presentation shall remain unaffected.

6. Representation by another Person (Section 20 of the German Insurance Contract Act (VVG))

In the event that you have yourself represented by another person when con-cluding the contract, both the knowledge and fraudulent intent on the part of your representative and your own knowledge and fraudulent intent shall be taken into account with respect to the reporting duty, the rescission, cancella-tion, contract amendment and the deadline for the execution of the Insurer’s rights. A reliance on an absence of intention or gross negligence when failing to comply with the reporting duty may only be relied on when neither your representative nor you can be made liable for intention or gross negligence.

Place, date Signatures (Applicant, if appropriate as legal representative of persons to be co-insured and all persons of full legal age to be insured)

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Registered office of the company: Hamburg • HRB 122052 Local court of Hamburg • Managing Director: Philipp Belau

Phone: +49-40-30 68 74-0 Fax : +49-40-30 68 74-90


WÜRZBURGER VERSICHERUNGS-AGConsent

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to the Collection and Use of Health Data and Declaration of Release from Secrecy towards Würzburger Versicherungs-AG (Versicherer)

The declarations of consent and release from secrecy according to Part I. were prepared on the basis of the coordination process between the Gesamtverband der deutschen Versicherungswirtschaft e.V. (GDV) and the data protection supervisory authorities.

CONSENT

Part I - Statement upon Application

The German Insurance Contract Act, the Federal Data Protection Act as well as ot-her data protection regulations do not provide for an adequate legal basis for the collection, processing and use of health data by insurance companies. In order to be able to obtain and use your health data in connection with this application and the contract, we therefore need your consent(s) according to data protection regulations. In addition, Würzburger Versicherungs-AG is in need of your state-ments of release from secrecy in order to be able to obtain your health data from parties subject to secrecy such as, for instance, physicians.

As health insurance company, Würzburger Versicherungs-AG needs your state-ment of release from secrecy also in order to be able to disclose your health data or any other data protected according to Section 203 StGB [German Criminal Code] such as, for instance, the fact that a contract has been concluded with you, to other entities or parties such as e.g. assistance, reinsurers.

The following statements of consent and release from secrecy are indispensable for checking your application and for concluding, implementing or terminating your insurance contract for Würzburger Versicherungs-AG. If you fail to make such statements, the conclusion of a contract will, as a rule, not be possible.

The statements relate to the handling of your health data and other data protec-ted according to Section 203 StGB

• on the part of the Würzburger Versicherungs-AG itself (see clause 1.);

• in connection with enquiries addressed to third parties (see clause 2.);

• when disclosing data towards entities or parties outside Würzburger Versiche-rungs-AG (see clause 3.), and

• if the contract fails to come into being (see clause 4.).

These statements will apply with respect to co-insured persons legally represen-ted by you, such as your children, to the extent that they are not able to recognise the significance of this consent and are therefore not able to make statements on their own.

1. Collection, storage and use of health data provided by you on the part of Würzburger Versicherungs-AG

I agree that Würzburger Versicherungs-AG collects, stores and uses the health data provided by me in connection with this application as well as in future to the extent that this is necessary for the examination of my ap-plication and for concluding, implementing and terminating this insurance contract.

2. Request for information on health issues from third parties

2.1 Request for health data from third parties for risk assessment and verification of the duty to indemnify

For assessing the risks to be insured, it may become necessary to obtain infor-mation from entities or parties retaining health data concerning your person. In addition, it may become necessary for Würzburger Versicherungs-AG to check the information on your health condition, as rendered by you for sub-stantiating your claims or as it can be derived from submitted documents (e.g. invoices, prescriptions, expert reports) or information rendered by, for instan-ce, a physician or other members of the medical profession, in order to verify its duty to indemnify. Such examination shall be carried out to the necessary extent only. Würzburger Versicherung-AG needs your consent thereto, inclu-sive of a release from secrecy for itself as well as for these parties for the case that health data or other information protected according to Section 203 StGB must be forwarded within the framework of such requests.

You may make these statements already here (I) or at a later time with respect to an individual case (II). You may change your decision at any time. Please select one of the following two options:

Option I:

I agree that - to the extent necessary for risk assessment or verification of the duty to indemnify - Würzburger Versicherungs-AG collects my health data from physicians, caregivers as well as employees in hospi-tals, other health institutions, care homes, personal insurers, statutory health insurance funds, trade associations and public authorities and uses them for these purposes.

I release the indicated persons and employees of the aforementioned institutions from their secrecy duties to the extent that health data permissibly stored with respect to my person and arising from exami-nations, consultations, treatments as well as insurance applications and contracts made during a period of up to ten years prior to the date of my application are disclosed towards Würzburger Versicherungs-AG.

In addition, I agree that in this context my health data are - to the extent necessary - disclosed by Würzburger Versicherungs-AG towards these parties or entities and, to this extent, also release the persons becoming active for Würzburger Versicherungs-AG from their secrecy duties.

Prior to every data collection according to the preceding paragraphs, I will be informed about the persons by whom and the purpose for which data are planned to be collected, and furthermore about the fact that I may raise objections and submit the required documents on my own.

Option II:

I want Würzburger Versicherung-AG to inform me in each individual case from which persons or entities and for what purpose information is required. Afterwards, I will decide whether I

• agree to the collection and use of my health data by Würzburger Versicherungs-AG, release the indicated persons or entities and their employees from their secrecy duties and agree to the disclosure of my health data to Würzburger Versicherungs-AG

• or whether I want to submit the required documents myself.

I am aware that this may result in a delay of application processing or the verification of the duty to indemnify. To the extent that the aforementioned declarations relate to my statements at the time of application, they shall be valid for a period of five years after contract conclusion.

If, after contract conclusion, Würzburger Versicherungs-AG becomes aware of specific circumstances indicating that, at the time of applicati-on, incorrect or incomplete information was deliberately furnished and, as a result, influence was exerted on risk assessment, the statements shall be valid for a term of up to ten years after contract conclusion.

2.2 Statements for the event of your death

In order to verify our duty to indemnify, it might become necessary to check health data even after your death. An examination may also become neces-sary if, up to a period of ten years after contract conclusion, Würzburger Ver-sicherungs-AG becomes aware of circumstances indicating that incorrect or incomplete information might have been rendered at the time of application and that, hence, influence was exerted on risk assessment. For this purpose, too, we need a consent and a statement of release from secrecy. Please select one of the following two options:

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Registered office of the company: Hamburg • HRB 122052 Local court of Hamburg • Managing Director: Philipp Belau

Phone: +49-40-30 68 74-0 Fax : +49-40-30 68 74-90


WÜRZBURGER VERSICHERUNGS-AGConsent

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Option I:

For the case of my death, I give my consent to a collection of my health data from third parties for the purpose of verifying a duty to indemnify or for examining the application again, if necessary, as described in the first checkbox (see above 2.1. - Option I).

Option II:

If, after my death, health data must be collected in order to verify a duty to indemnify or to examine the application again, my heirs or - if different - the beneficiaries of the contract shall be authorised to deci-de upon consents and statements of release from secrecy.

3. Disclosure of health data and other data protected according to Section 203 StGB to entities or parties outside Würzburger Versicherungs-AG

Würzburger Versicherungs-AG contractually obliges the following entities or parties to comply with the provisions on data protection and data security.

3.1 Disclosure of data for medical assessment

In order to assess the risks to be insured and to verify the duty to indemnify, it may become necessary to involve medical experts. Würzburger Versiche-rungs-AG is in need of your consent and statement of release from secrecy if, in this context, your health data and other data protected according to Section 203 StGB are disclosed. You will be given notice of the respective data disclosure.

I agree that Würzburger Versicherungs-AG transfers my health data to me-dical experts if this is necessary within the framework of risk assessments or verifications of the duty to indemnify and that my health data are used there according to the purpose of the transfer and that the results are sent back to Würzburger Versicherungs-AG. With respect to my health data and other data protected according to Section 203 StGB, I release the persons active for Würzburger Versicherungs-AG and the experts from their secrecy duties.

3.2 Delegation of tasks to other entities or parties (business ent-erprises or persons)

Some tasks such as, for instance, risk assessments, processing of submit-ted claims or customer service by phone, which may involve the collection, processing and use of your health data, are not carried out by Würzburger Versicherungs-AG itself, but instead delegated to another entity or party. If, in this context, your data protected according to Section 203 StGB are disclosed, Würzburger Versicherungs-AG needs your statement of release from secrecy for itself and, where appropriate, for the other entities or parties.

BDAE Expat GmbH as policyholder maintains a constantly updated list where the entities/parties and categories of entities/parties contractually engaged in collecting, processing or using health data for BDAE Expat GmbH and Würz-burger Versicherungs-AG as well as the delegated tasks are indicated. The currently valid list is available on the Internet under www.bdae.com/images/forms/docs/en/List_of_service_providers.pdf or can be obtained from the data protection officer of the BDAE Group, HUBIT e.K., Postfach 610120, 28261 Bremen, e-mail: [email protected]. In order to be able to disc-lose your health data towards the entities/parties mentioned in this list and to have them processed your data, we and Würzburger Versicherungs-AG are/is in need of your consent.

I agree that Würzburger Versicherungs-AG discloses my health data towards the entities/parties indicated in the aforementioned list and that the health data are collected, processed and used there for the indicated purposes to the same extent as Würzburger Versicherungs-AG would be allowed to do. To the necessary extent, I release the employees of Würzburger Versicherungs-AG and other parties or entities from their secrecy duties with respect to the disclosure of health data and other data protected according to Section 203 of the StGB.

3.3 Data disclosure to reinsurers

For the purpose of safeguarding your claims, Würzburger Versicherungs-AG may involve reinsurers who assume the risk either totally or in part. In some instances, the reinsurers make use of other reinsurance companies for such purposes so that your data will also be disclosed towards such other reinsurance companies. In order to enable the reinsurers to get their own impressions of the risk or insured event, Würzburger Versicherungs-AG might submit your application form or claims for payment of benefits to the reinsu-rance companies. This will particularly be the case when the insurance sum is especially high or the risk is difficult to assess. Moreover, it is possible that the reinsurance company renders assistance to Würzburger Versicherungs-AG on the basis of its special expertise during the risk assessment process or verification of the duty to indemnify as well as during the assessment of process sequences. If reinsurers have hedged the risk, they can monitor whether Würzburger Versicherungs-AG has assessed the risk or an insured event correctly. In addition, data on your existing contracts and applications are disclosed towards reinsurers to the required degree so that they are able to check whether and to what amount they can participate in the risk. Data on your existing contracts may be forwarded to reinsurers for the purpose of billing premium payments and settling insured events. For the aforemen-tioned purposes, anonymised or pseudonymised data, if possible, but also personal health data will be used. A use of your personal data by reinsurance companies will be limited to the aforementioned purposes. Würzburger Ver-sicherungs-AG will give you notice about a disclosure of your health data to reinsurers.

I agree that my health data are - to the necessary extent - forwarded to reinsurers and used by them for the indicated purposes. I release persons active for Würzburger Versicherungs-AG to the necessary extent from their secrecy duties with respect to health data and other data protected according to Section 203 StGB.

3.4 Disclosure of data to self-employed intermediaries

As a rule, Würzburger Versicherungs-AG does not disclose data on your health state to self-employed intermediaries. In the following events, howe-ver, data permitting conclusions on your health or information on your con-tract, as protected according to Section 203 StGB, might be disclosed towards insurance intermediaries for information purposes. To the extent required for contract-related consultation purposes, the intermediary supporting you might receive information on the fact whether and, when appropriate, under what conditions (e.g. acceptance of a risk markup, exclusion of certain risks) your contract can be accepted. The intermediary having submitted your contract will get knowledge of a contract conclusion and its content. In this context, the intermediary will also be informed whether risk markups or exclusions of certain risks have been agreed upon. If you change the inter-mediary supporting you, the contract data containing the information on risk markups and exclusions of certain risks may be disclosed towards the new intermediary. When you change the intermediary who supports you we will give you notice of the disclosure of health data towards the new agent and of your possibility to raise objections.

I agree that, in the aforementioned events, Würzburger Versicherungs-AG discloses my health data and other data protected according to Section 203 StGB to the required extent towards the self-employed insurance in-termediary who is in charge of my affairs and that such data are collected, stored and used there for consultation purposes.

4. Storage and use of your health data if the contract fails to come into being

If a contract with you fails to come into being, Würzburger Versicherungs-AG will retain your health data collected within the framework of the risk assess-ment for the case that you apply for insurance coverage again. Würzburger Versicherungs-AG will also store your data in order to give a reply to enquiries, if any, by other insurance companies. Your data will be stored by Würzburger Versicherungs-AG until expiry of the third calendar year after the year of application.

I agree that Würzburger Versicherungs-AG may, for the aforementioned purposes, store and use my health data in case that the contract fails to come into being for a period of three years after the expiry of the calendar year during which the application was filed.

Place, Date Signatures (Applicant), if appropriate as legal representative of persons to be co-insured and all persons of full age to be insured)

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HEALTH CERTIFICATE FOR APPROVAL OF AN APPLICATION FOR HEALTH INSURANCE EXPAT RETIREDEXAMINATION COSTS WILL BE BORNE BY THE APPLICANT! TO SUBMIT WITH AGE OF 60 AND ABOVE

Stand: 21.10.2019

HEALTH CERTIFICATE TOWARDS WÜRZBURGER VERSICHERUNGS-AG (INSURER)

1


Surname: First name(s): Date of birth:

Address:1. DECLARATION TO THE DOCTOR:

ANSWER IF YES: WHICH, TREATED WHERE (DOCTOR), DIAGNOSIS1.a Are you currently suffering from complaints,

illnesses or the results of accidents?

oYes oNo

1.b Do you or have you suffered from a chronic

or repetitious illness?

oYes oNo

1.c Have you been examined, advised or treated

by medical staff (e.g. doctors, consultants,

medical practitioners, psychologists, masseurs..)

in the last three years or have you been

unable to work - even temporarily?

oYes oNo

1.d Have operations or treatment been per-

formed, planned or advised?

oYes oNo

1.e Has hospital treatment (including clinics,

sanatoriums etc.) taken place in the last 5

years?

oYes oNo

1.f Have blood examinations been performed?

With which results?

oYes oNo

1.g Has an HIV infection been determined, e.g.

by an AIDS test?

oYes oNo

1.h Have you had or are you engaged in cytosta-

tic treatment?

oYes oNo

1.i Do you or have you regularly imbibed medi-

cines, alcohol or drugs?

oYes oNo

1.j Do you have impaired sight or do you re-

quire an aid to vision (e.g. spectacles, con-

tact lenses)? Dioptre?

oYes oNo

1.k Which doctor do you usually consult?

(Regular GP)1.l

1.m

Is dental treatment necessary, particularly

with regard to dentures, dental surgery or

parodontosis?

oYes oNo

Are you pregnant? oYes oNo

I hereby confirm with my handwritten signature that the above declaration is a part

of my application for health insurance and that the I have answered the above

questions dictated to me individually by the doctor personally and truthfully.

Place / Date:

Signature of the applicant: Anamnesis performed (Stamp / Signature of the doctor):

WHEN?

Stand: 21.10.2019

2

Surname: First name(s):

EXAMINATION DIAGNOSIS FOR:

2. GENERAL:ANSWER DIAGNOSIS / DEVIATIONS / EXPLANATION

2.a Have you examined, advised or treated the

person in the past?

oYes oNo

2.b Height:

Weight:

cm

kg2.c Do you consider the skeleton and locomo-

tion to be healthy?

oYes oNo

2.d Do you consider the skin, mucous mem-

branes and lymph glands to be healthy?

oYes oNo

2.e Do you consider the sensory organs to be

healthy?

oYes oNo

2.f Do you consider the nervous system and psy-

che to be healthy?

oYes oNo

2.g Are the reflexes normal? oYes oNo

2.h Do you consider the hormonal system to be

healthy?

oYes oNo

2.i Is the thyroid gland normally shaped? oYes oNo

3. CARDIOVASCULAR SYSTEM:3.a Pulse at rest

After 10 knee bends

Return to normal in minutes

mm Hg

mm Hg

Blood pressure at rest

After 10 knee bends

3.b

3.c Can unhealthy hear sounds be heard? oYes oNo

3.d Is the heart arrhythmic? oYes oNo

Is the heart enlarged or displaced? oYes oNo3.e

3.f Are there any signs of insufficiency? oYes oNo

3.g Does the patient have dyspnoea? oYes oNo

4. BLOOD VESSELS:4.a Is the patient oedemic? oYes oNo

4.b Does the patient have haemorrhoids, vari-

cose veins? (type? / extent?)

oYes oNo

4.c Does the patient have scars, ulcers?

(type? / extent?)

oYes oNo

5. RESPIRATORY ORGANS:5.a Does the patient suffer from hoarseness,

coughs, bronchitis? (since when? extent?)

oYes oNo

5.b Is the rib cage deformed? oYes oNo

5.c Are the results of the percussion and auscul-

tation examinations normal?

oYes oNo

5.d Do you consider die respiratory organs to be

healthy?

oYes oNo

6. DIGESTIVE AND ABDOMINAL ORGANS:6.a Signs of illness on the tongue, tonsils,

throat?

oYes oNo

6.b Are the examination results of the abdomen

normal?

oYes oNo

6.c Is the liver enlarged? oYes oNo

6.d Is the pancreas enlarged? oYes oNo

6.e Does the patient suffer from a rupture? oYes oNo

/

/

2.j Are you suspicious of an organic disorder? oYes oNo

Stand: 21.10.2019

f missing teeth e replaced teeth K crowned teeth b bridged teeth s teeth in need of rehabilitation )( space closure

3

ANSWER IF YES: WHICH, TREATED WHERE (DOCTOR), DIAGNOSIS9.a Are there gum diseases? oYes oNo

WHEN?9. DENTAL:

7.


URINAL AND SEXUAL ORGANS:

ANSWER

7.a Is the condition of the renal capsule normal? oYes oNo

DIAGNOSIS / DEVIATIONS / EXPLANATION

EXAMINATION DIAGNOSIS FOR:

7.b urine examination:

exterior condition:

pathological components:

protein

sugar

bile pigment high

oYes oNo

oYes oNo

oYes oNo

sediment:

7.c

8.8.a

8.b Are there signs of an immune disorder?

oYes oNo

oYes oNo

OTHER ASPECTS THAN THE EXAMINATION RESULTS ARE SOMETIMES DECISIVE IN THE EVALUATION OF THE RISK.PLEASE DO NOT DISCLOSE ANY INFORMATION OF THE INSURANCE RISK.

Regarding woman: Pregnancy? oYes oNo in ______ month

MISCELLANEOUS:What other disorders and still unnamed di-

agnoses were found?

Place / Date Stamp / Signature of the doctor

DETAILS OF THE DENTAL STATUS

DENTAL STATUSDIAGNOSIS OF ALL TEETH

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

DIAGNOSIS

18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

DIAGNOSIS / LEGEND:

Stamp / Signature of the dentistPlace / Date

6.f Unhealthy diagnosis of the digestive organs? oYes oNo

Stand: 21.10.2019




EXPAT RETIRED



Please answer all the questions below. Please also include ailments which you regarded as unimportant or which you did not view as illnesses, even if you did not receive

treatment, but only had an examination or test or only took medicines and were not incapacitated. If you supply incorrect or insufficient information you may loose

your insurance cover.

SECOND PERSONFIRST PERSONDETAILS ABOUT INSURED PERSONS:

The following questions must be answered for each insured

person listed in the application according to the information

supplied by the insured persons. In the case of minors, the

questions must be answered in accordance with the informa-

tion supplied by the guardian.

If there are more than two insured persons, please use addition-

al copies of this form.

Surname:

First name(s):

Date of birth:

Size:

Weight:

cm

kg

cm

kg

1. Do you currently suffer from ailments, illnesses, the effects of an accident,

physical or mental disorders? (including teeth)

2. Have you been taking medicines, alcohol or drugs on a daily or almost daily

basis for the last five years?

3. Is an examination, check-up, treatment or operation required at this time?

Please also supply information on dental treatments, dentures, orthodontic

measures, or paradontosis treatments.

4. Have you had inpatient or outpatient examinations / treatments or opera-

tions by doctors, dentists, healers, psychologists or masseurs or have you

been in hospital for the last five years? (Please also supply information about

cures and stays at sanatoriums).

5. If the EXPAT RETIRED TOP module has been applied for: do you have defec-

tive vision i.e. do you require glasses or contact lenses? Please give details

(dioptre number).

Please give details on the questions which you answered with "Yes" (state the person(s) and the number(s) of the questions / use an additional sheet of paper if necessary):

oYes oNo oYes oNo

oYes oNo oYes oNo

oYes oNo oYes oNo

oYes oNo oYes oNo

oYes oNo oYes oNo

Left: Right: Left: Right:

Insured

person

Question

no.

Detailed description of illness,

type of ailment

Treatment(s)

received inpatient / outpatient? Dates

Do you still

suffer from consequences?

If yes, please give details.

Please give the names of the doctors who can supply more detailed information. If all questions have been answered with "No", please indicate the name, specialist

field and exact address of the doctor who can supply the most up-to-date information.

First Person:

Second Person:

Place, date: Signature:

(applicant or legal guardian of persons who are to be included in the insurance and all

adults to be insured)

HEALTH DECLARATION TOWARDS WÜRZBURGER VERSICHERUNGS-AG (INSURER)