<p style="text-align: center;">&nbsp;<img alt="" src="http://193.70.73.91/wp-content/uploads/2020/01/Asset-2logo-tr.png" style="margin: 10px 20px; width: 308px; height: 47px;" /></p>

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<p style="margin-top:0pt; margin-bottom:14pt; text-align:center; font-size:16pt;"><strong><span style="font-family:Montserrat; color:#ff6600;">ATTESTATION D&#39;ASSURANCE VOYAGE TOURISTIQUE</span></strong><br />
<strong><span style="font-family:Montserrat; color:#339999;">CERTIFICAT N&deg;MC-GSL-VTIXXXXXX</span></strong></p>

<p style="margin-top:0pt; margin-bottom:0pt; text-align:center; font-size:10.5pt;"><strong><span style="font-family:'Myriad Pro'; color:#ff6600;">Certificat en conformit&eacute; avec les exigences internationales pour les s&eacute;jours courts et pour les longs.</span></strong></p>

<p style="margin-top:14pt; margin-bottom:14pt; text-align:center; font-size:9pt;"><strong><span style="font-family:'Myriad Pro';">MONDIALCARE&copy; par AGIS SAS</span></strong><span style="font-family:'Myriad Pro';">&nbsp;atteste par la pr&eacute;sente que l&#39;assur&eacute; d&eacute;nomm&eacute; ci-apr&egrave;s est garanti par le contrat GSL</span><br />
<strong><span style="font-family:'Myriad Pro';">N&deg; ADP20192393 REF GSL-AGISSCHENGEN082019</span></strong><span style="font-family:'Myriad Pro';">&nbsp;suivant les prestations d&eacute;crites dans les conditions g&eacute;n&eacute;rales.</span></p>

<p style="margin-top: 14pt; margin-bottom: 14pt; font-size: 10pt; text-align: center;"><strong>MONDIALCARE&copy; par AGIS SAS</strong> atteste par la pr&eacute;sente que l&#39;assur&eacute; d&eacute;nomm&eacute; ci-apr&egrave;s est garanti par le contrat GSL<br />
<strong>N&deg; ADP20192393 REF GSL-AGISSCHENGEN082019 </strong>suivant les prestations d&eacute;crites dans les conditions g&eacute;n&eacute;rales.</p>

<p style="margin-top: 14pt; margin-bottom: 14pt; font-size: 10pt; text-align: center;">L&#39;assur&eacute;(e) d&eacute;sign&eacute;(e) sur cette attestation d&rsquo;assurance, b&eacute;n&eacute;ficie des garanties d&eacute;finies aux conditions g&eacute;n&eacute;rales<br />
valant notice d&rsquo;information jointes en annexe et selon ses options, montants de garanties et de franchises figurant aux tableaux ci-apr&egrave;s.</p>

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			<p style="margin-top:0pt; margin-bottom:0pt; text-align:center; font-size:12pt;"><strong><span style="font-family:Montserrat; color:#ff6600;">INFORMATIONS DE L&rsquo;ASSURE(E) BENEFICIAIRE DES GARANTIES</span></strong><br />
			<span style="font-family:'Myriad Pro'; font-size:10pt;">P&eacute;riode de Garantie : du&nbsp;</span><strong><span style="font-family:'Myriad Pro'; font-size:10pt;">[date-depart]</span></strong><span style="font-family:'Myriad Pro'; font-size:10pt;">&nbsp;au&nbsp;</span><strong><span style="font-family:'Myriad Pro'; font-size:10pt;">[date-fin]&nbsp;</span></strong><span style="font-family:'Myriad Pro'; font-size:10pt;">inclus &ndash; soit&nbsp;</span><strong><span style="font-family:'Myriad Pro'; font-size:10pt;">[resultatDuree]</span></strong><span style="font-family:'Myriad Pro'; font-size:10pt;">&nbsp;jours</span><br />
			<span style="font-family:'Myriad Pro'; font-size:10pt;">Pays de Provenance</span><span style="font-family:'Myriad Pro'; font-size:10pt;">&nbsp;</span><span style="font-family:'Myriad Pro'; font-size:10pt;">:&nbsp;</span><strong><span style="font-family:'Myriad Pro'; font-size:10pt;">[provenance_pays]</span></strong><span style="font-family:'Myriad Pro'; font-size:10pt;">&nbsp;&ndash; Pays de Destination :&nbsp;</span><strong><span style="font-family:'Myriad Pro'; font-size:10pt;">[destination_pays]</span></strong></p>
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						<p style="margin-top:0pt; margin-bottom:0pt; text-align:center; font-size:10pt;"><strong><span style="font-family:Montserrat; color:#ffffff;">Identit&eacute; de l&#39;assur&eacute;(e)</span></strong></p>
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						<p style="margin-top:0pt; margin-bottom:0pt; text-align:center; font-size:10pt;"><strong><span style="font-family:Montserrat; color:#ffffff;">Coordonn&eacute;es de l&#39;assur&eacute;(e)</span></strong></p>
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						<p style="margin-top:0pt; margin-bottom:0pt; font-size:10pt;"><span style="font-family:'Myriad Pro';">Nom :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[personne--nom]</span></strong><br />
						<span style="font-family:'Myriad Pro';">Pr&eacute;nom(s) :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[personne--prenom]</span></strong><br />
						<span style="font-family:'Myriad Pro';">Date de Naissance :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[personne--date-naiss]</span></strong><br />
						<span style="font-family:'Myriad Pro';">Nationalit&eacute; :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[personne--nationalite]</span></strong><br />
						<span style="font-family:'Myriad Pro';">N&deg; Passeport :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[personne--numpass]</span></strong></p>
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						<p style="margin-top:0pt; margin-bottom:0pt; font-size:10pt;"><span style="font-family:'Myriad Pro';">Adresse de r&eacute;sidence :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[adresse-payeur]</span></strong><br />
						<span style="font-family:'Myriad Pro';">Pays de r&eacute;sidence :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[pays-payeur]</span></strong><br />
						<span style="font-family:'Myriad Pro';">Ville de r&eacute;sidence :&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[ville-payeur]</span></strong><br />
						<strong>Num&eacute;ro de Mobile</strong><span style="font-family:'Myriad Pro';"> : </span><strong><span style="font-family:'Myriad Pro';">[ind_mobile-payeur][telephone_mobile-payeur]</span></strong><br />
						<span style="font-family:'Myriad Pro';">Adresse E-mail : </span><strong><span style="font-family:'Myriad Pro';">[email-payeur]</span></strong></p>
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			<p style="margin-top:0pt; margin-bottom:0pt; text-align:center; font-size:9pt;"><strong><span style="font-family:'Myriad Pro';">Option Responsabilit&eacute; Civile Vie Priv&eacute;e Voyage souscrite pendant l&rsquo;inscription</span></strong><strong><span style="font-family:'Myriad Pro';">&nbsp;</span></strong><strong><span style="font-family:'Myriad Pro';">?</span></strong><span style="font-family:'Myriad Pro';">&nbsp;</span><strong><span style="font-family:'Myriad Pro';">[personne--option]</span></strong></p>
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<p style="margin-top: 14pt; margin-bottom: 14pt; font-size: 10pt; text-align: center;"><strong><span style="font-family:'Myriad Pro';">Pour toutes demandes d&rsquo;Assistance</span></strong><span style="font-family:'Myriad Pro';">, l&rsquo;Assur&eacute;(e) (ou toute personne agissant en son nom)<br />
doit contacter GROUPAMA ASSISTANCE au <strong><span style="font-family:'Myriad Pro';">+33 1 55 98 57 35 </span></strong>(joignable 7 jours sur 7, 24h sur 24)</span><br />
<span style="font-family:'Myriad Pro';">en rappelant la r&eacute;f&eacute;rence du contrat <strong>GSL N&deg; ADP20192393 REF GSL-AGISSCHENGEN082019</strong></span></p>

<p style="margin-top: 14pt; margin-bottom: 14pt; font-size: 11pt; text-align: center;"><strong><span style="font-family:'Myriad Pro'; font-size:10pt;">Pour tout autre renseignement et demande de remboursement FRAIS M&Eacute;DICAUX-HOSPITALISATION :</span></strong><br />
<span style="font-family:'Myriad Pro'; font-size:10pt;">Contacter <strong>MONDIALCARE&copy;</strong> par l&#39;intermediaire de AGIS SAS - 33 Avenue Victor Hugo 75784 Paris Cedex 16</span><br />
<span style="font-size:14px;"><span style="font-family: &quot;Myriad Pro&quot;;">T&eacute;l&eacute;phone : +33183825626&nbsp;</span><span style="font-family: &quot;Myriad Pro&quot;;">ou par E-mail :&nbsp;</span> <a href="mailto:contact@mondialcare.eu" style="text-decoration:none;"><u><span style="font-family: &quot;Myriad Pro&quot;; color: rgb(5, 99, 193);">contact@mondialcare.eu</span></u></a></span></p>

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						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;" width="5">✔</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">Frais m&eacute;dicaux, chirurgicaux, pharmaceutiques, d&rsquo;hospitalisation**</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">&nbsp;</td>
						<td align="right" style="border-spacing: 0; text-align: right; color: #003399; padding: 8px; border: none;">[OPT35100K]</td>
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						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;" width="5">✔</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">Assistance m&eacute;dicale compl&egrave;te</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">&nbsp;</td>
						<td align="right" style="border-spacing: 0; text-align: right; color: #003399; padding: 8px; border: none;">Frais r&eacute;els</td>
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						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;" width="5">✔</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">Rapatriement sanitaire</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">&nbsp;</td>
						<td align="right" style="border-spacing: 0; text-align: right; color: #003399; padding: 8px; border: none;">Frais r&eacute;els</td>
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						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;" width="5">✔</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">Rapatriement du corps en cas de d&eacute;c&egrave;s</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">&nbsp;</td>
						<td align="right" style="border-spacing: 0; text-align: right; color: #003399; padding: 8px; border: none;">Frais r&eacute;els</td>
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			<p>&nbsp;<strong><span style="font-family:Montserrat; color:#ff6600;">GARANTIES SI OPTION RESPONSABILITE CIVILE VIE PRIVEE<input name="option" type="checkbox" /></span></strong></p>

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						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;" width="5">✔</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">Responsabilit&eacute; civile vie priv&eacute;e &ndash; dommages mat&eacute;riels</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">&nbsp;</td>
						<td align="right" style="border-spacing: 0; text-align: right; color: #003399; padding: 8px; border: none;">&euro; 350 000</td>
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						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;" width="5">✔</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">Responsabilit&eacute; civile Vie Priv&eacute; &ndash; dommages corporels</td>
						<td style="border-spacing: 0; color: #003399; padding: 8px; border: none;">&nbsp;</td>
						<td align="right" style="border-spacing: 0; text-align: right; color: #003399; padding: 8px; border: none;">&euro; 1 500 000</td>
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			<p style="margin-top: 14pt; margin-bottom: 0pt; font-size: 8pt; text-align: center;"><span style="font-family:'Myriad Pro';">**avant toute intervention chirurgicale nous finan&ccedil;ons une seconde opinion syst&eacute;matiquement</span></p>
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<p style="margin-top: 14pt; margin-bottom: 14pt; font-size: 8pt; text-align: center;"><span style="display: none;">&nbsp;</span><span style="font-family:'Myriad Pro';">L&#39;assur&eacute; reconna&icirc;t avoir pris connaissance de l&#39;ensemble des informations figurant sur son contrat et les conditions g&eacute;n&eacute;rales. Ce contrat est &eacute;tabli selon ses d&eacute;clarations;<br />
le code des assurances pr&eacute;voit express&eacute;ment la nullit&eacute; du contrat (article L113.8 du Code des assurances) en cas de fausse d&eacute;claration ou de d&eacute;claration incompl&egrave;te.<br />
L&#39;assur&eacute; autorise son assureur &agrave; communiquer les informations relatives &agrave; son contrat &agrave; toute personne qui pourrait en avoir besoin en raison de sa gestion ou de son ex&eacute;cution.<br />
L&#39;assur&eacute; dispose d&#39;un droit d&#39;acc&egrave;s et de rectification pour toute information le concernant, qu&#39;il pourra exercer aupr&egrave;s de notre si&egrave;ge ou contactez DPO EXPERT au 01 4227 7349 &agrave; dpo@agis-group.com</span><span style="display: none;"> </span></p>

<p style="margin-top:14pt; margin-bottom:14pt; text-align:center; font-size:12pt;"><img alt="" src="http://193.70.73.91/wp-content/uploads/2020/01/Asset-3logo-tr.png" style="width: 69px; height: 47px;" /><br />
<strong><span style="font-family:'Myriad Pro'; color:#339999;">www.</span></strong><strong><span style="font-family:Montserrat; color:#339999;">MONDIALCARE</span></strong><strong><span style="font-family:'Myriad Pro'; color:#339999;">.eu</span></strong></p>
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<p style="text-align: center;"><strong><span style="font-family:'Myriad Pro'; font-size:6pt;">MONDIALCARE &copy; par AGIS SAS - 33 Avenue Victor Hugo 75784 Paris Cedex 16 - T&eacute;l : + 33 6 09 24 81 39 ou +33 1 82 83 56 26</span></strong><br />
<span style="font-family:'Myriad Pro'; font-size:7pt;">RCS Paris B 524 120409 Garantie Financi&egrave;re et responsabilit&eacute; civile professionnelle conformes &agrave; la loi Immatriculation sous le num&eacute;ro 10057380 au registre des Interm&eacute;diaires d&#39;Assurances </span><br />
<span style="font-family:'Myriad Pro'; font-size:7pt;">Orias - 1 rue Jules Lef&egrave;vre - 75311 Paris Cedex 9 - Activit&eacute; exerc&eacute;e sous le contr&ocirc;le de l&#39;ACP - 61 rue Taitbout - 75009 Paris</span></p>
