Mr William Ajhuacho Jagowstrae 28 10555 Berlin

Please contact: Care Concept AG Am Herz-Jesu-Kloster 20 53229 Bonn +49 228 97735-11 vertrag@care-concept.de 16.Oktober 2012

Insurance certificate for health insurance Care Economy Details of the insurance Insurance Insurance-Nr. Care Economy E129935020

Inception date* 17.10.2012

Term of insurance 80 days

One-off 82,40

* Information about the inception date a) for persons to be insured who have not entered yet and need a visa to do so: The insurance cover is valid for entries within a period of 6 months from the inception date. At a later entry insurance cover exists for a period of 80 days from the date of entry. In event of claim, proof of the exact date of entry (e.g. by copy of notes inside passport) as well as the visa has to be established. b) for persons to be insured who do not need a visa to enter or have entered already: The Insurance begins at 17.10.2012 and lasts for 80 days in total.

Policyholder Salutation Mr. Insured person Salutation Mr. Native country Bolivien

Last name, First name Ajhuacho, William

Last name, First name Ajhuacho, William Nationality Bolivien

Country of stay Deutschland

Date of birth 01.11.1978 Entry 16.10.2012

The insurance cover complies with the requirements of Regulation (EC) No 810/2009 of the European Parliament and the Council of the European Union by 07/13/2009 and is not limited to EUR 30,000. Cover includes medically necessary repatriation, as well as out-patient and in-patient treatments. The scope extends to the countries of the European Union and the member states of the Schengen Agreement. This confirmation of insurance cover applies explicitly for submission to immigration authorities, embassies, consulates and border stations. Consent clause: Points in italic and bold text in the insurance certificate differ from the application. Unless you object in writing within one month of receipt of the insurance certificate, these differences are deemed accepted. For other important information and legal consequences, please refer to the reverse side also.

Dr. Gent

Sautter

Board: Fritz Horst Melsheimer (Chairman), Eberhard Sautter (VC), Eric Bussert, Holger Ehses, Dr. Andreas Gent, Dr. Wilfried Hauck Chairman of the Supervisory Board: Jrg G. Schiele Trade register: Hamburg B 19768 VAT ID: DE 175218900 Siegfried-Wedells-Platz 1 20354 Hamburg

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Details of premium payment: The premium will be paid all at once by bank transfer. This insurance is valid only in conjunction with valid proof of payment (bank statement, stamped bank transfer form, cash payment receipt).

For individual policies, the content of your policy is derived from the information in the insurance certificate. The scope and content of your cover is based on this insurance certificate, any subsequent addenda, the General Terms & Conditions of Insurance, including tariff with tariff conditions, the bylaws and statutory requirements especially the German Insurance (Policies) Act (Gesetz ber den Versicherungsvertrag - VVG). Addenda to the insurance certificate show the latest status of your policy. Where the content of the insurance certificate or any addendum differs from the application for cover, the change shall be deemed accepted unless you object to it in writing within one month of receiving the certificate ( 5 VVG). You have the right to revoke your contract agreement in written form within 14 days of receiving these documents, whereby that period begins on the date of receiving the insurance policy. Timely sending of your revocation is authoritative in determining adherence to this notice period. Important note in accordance with 37 para 2 VVG: If an insurance event occurs after the policy has been taken out, but the single or initial insurance premium has not been paid at this point in time, HanseMerkur shall not be obliged to pay benefits, unless non-payment is not the policy-holders fault. Beyond the content of the individual policy, the provisions of the respective group insurance policy also apply to group insurance.

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