Surname: .........................................................................................
First name(s): ....................................................................................
Date of birth: .....................................................................................
Place of birth: ....................................................................................
Passport Nr.: .....................................................................................

Having been provided with the relevant information by the German Embassy Kuwait,
I hereby declare:

“The enclosed travel health insurance policy (original and copy) is proof of the re-
quired 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.”

Criteria for travel health insurance:
- 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.

Kuwait, _____________
Date, signature of applicant

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.