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Applicant’s Name ( as per passport)

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Date and Place of Birth of the Applicant ( as per passport)

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Applicant’s Passport Details (Number, Date and Place of Issue, Date of Expiry)

With regard to my visa application dated _____________ I herewith declare that according to the Schengen regulations, I will be in possession of an adequate travel health insurance valid for the complete duration of my stay(s) in Schengen- Territory.

Having been provided with the relevant information by the German Consulate in Dubai,

I hereby declare:

„The enclosed travel health insurance policy (original and copy) is proof of the required travel health

insurance cover for the duration of my first stay in the Schengen area, should I be granted the visa applied for on______________ (Date of application).

Furthermore, I expressly declare that I have been informed that for every future stay in the Schengen area I must take out a travel health insurance policy which fulfils the criteria listed below and that I must always carry with me proof of insurance cover in the original for presentation on request during any border controls.“

I have been informed that a proof of a travel medical insurance (insurance policy document) has to be carried along when travelling to the Schengen States.

Health Insurance Requirements:

• The validity of the Travel Health Insurance corresponds to or exceeds the duration of my intended trip to the Schengen Area
• Minimum insurance cover per person must be EUR 30,000
• The policy must be valid in all Schengen states
• The insurance company must have an office in a Schengen state, Switzerland or in Liechtenstein
• The policy must cover the cost of possible repatriation in the event of illness, urgent medical treatment and/or emergency hospital treatment.

Besides, I understand that I have to present a Travel Health Insurance according to the above mentioned specifications for all subsequent visits to the Schengen Area.

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Place, Date

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Applicant’s Signature

Note: In cases where the purpose of the stay is to undergo medical treatment, proof of ability to pay the cost of any treatment not covered by the abovementioned insurance policy must be provided separately.