Proof of Insurance World-Wide policy All students traveling with EF International Language Campuses are required to have adequate travel Insurance coverage from the time of departure until the return to their home country. A tailor made group travel insurance coverage is automatically included. Should you wish to renounce this coverage you need to fill out this form together with your own insurance company and send it back to EF for approval. All details below and page 2 need to be filled out. The Insurance has to cover medical expenses in case of Illness and Accident as well as Emergency Home Evacuation. Third Party Liability coverage is also required for all students. This Proof of Insurance needs to be signed and sent in original to EF International Language Campuses latest at due date of Final Invoice for full payment of course.
Student information First Name ___________________________________________ Last Name ______________________________________________ EF Booking #_________________________________________ Destination Country ______________________________________
Insurance company information Name ________________________________________________________________________________________________________ Address _____________________________________________ Telephone _______________________________________________ Post Code ____________________ City _______________________________Country _____________________________________ Policy Number ________________________________________________________________________________________________ Emergency Assistance Agent and Emergency telephone number ______________________________________________________ _____________________________________________________________________________________________________________ Price of Insurance _____________________________________________________________________________________________
Note that the insurance needs to be valid worldwide and cover the student not only while in school but 24/7. If the student is extending the length of the course the Insurance needs to be extended to cover the extended period. If student elects to extend its stay with EF International Language Campuses a new Proof of Insurance needs to be issued which states the extension policy until student returns to home country. This new Proof of Insurance will be sent to EF International Language Campuses office within 24 hours of extension.
Student/parent/legal guardian signatures I/We have read and understood the above information for the required insurance coverage. I/We also understand that meeting the stated minimum requirements (page 2) is necessary to be admitted to the school. I/We furthermore undertake and agree to pay all costs in connection with treatment, evacuation or repatriation (of our child), and to hold harmless EF International Language Campuses for any damages that I/our child may cause. I/We also understand that I/the student need/s to bring the insurance policy, and card to the school on the start date of the course. Student ______________________________________________________________________________________________________ Signature _____________________________________________________________________________________________________ Date _________________________________________________________________________________________________________ Mother/Legal guardian ________________________________ Father/Legal guardian _____________________________________ Signature ____________________________________________ Signature________________________________________________ Date ________________________________________________ Date____________________________________________________
Travel Insurance (included)
Other Insurance
Illness & Accident in USD
Illness & Accident
Medical Expenses
Unlimited
Medical Expenses
Emergency Home Evacuation
Unlimited
Emergency Home Evacuation ___________________________
Family Member Visit
Unlimited
Family Member Visit
___________________________
Home Repatriation
Unlimited
Home Repatriation
___________________________
Accidental Death
100,000
Accidental Death
___________________________
Accidental Disability
100,000
Accidental Disability
___________________________
Program Interruption
in USD ___________________________
Program Interruption
Program Interruption
unused part of program fee
Program Interruption
___________________________
Flight extra cost
unlimited
Flight extra cost
___________________________
Return flight to program
2,000
Return flight to program
___________________________
Personal Property
Personal Property Personal Belongings
4,000
Personal Belongings
___________________________
Cash
500
Cash
___________________________
Valuable Documents
2,000
Valuable Documents
___________________________
Delay
Delay Baggage Delay
200
Baggage Delay
___________________________
Personal Delay
900
Personal Delay
___________________________
Liability & Legal
Liability & Legal Third Party Liability
100,000
Third Party Liability
___________________________
Legal Expenses
15,000
Legal Expenses
___________________________
I N T E R N AT I O N A L L A N G U AG E CAMPUSES
日本語訳と記入例
Proof of Insurance World-Wide policy
LS【2024】
英文を正文とします。英文の用紙に記入頂き、提出をお願い致します。
All students traveling with EF International Language Campuses are required to have adequate travel Insurance coverage from the time of departure until the return to their home country. A tailor made group travel insurance coverage is automatically included. Should you wish to renounce this coverage you need to fill out this form together with your own insurance company and send it back to EF for approval. All details below and page 2 need to be filled out. The Insurance has to cover medical expenses in case of Illness and Accident as well as Emergency Home Evacuation. Third Party Liability coverage is also required for all students. This Proof of Insurance needs to be signed and sent in original to EF International Language Campuses latest at due date of Final Invoice for full payment of course. EF インターナショナル・ランゲージ・キャンパスに参加するすべての方は、留学出発日から帰国日までが保険期間となる海外旅 行傷害保険への加入が必要です。各 EF プログラムのお申込み内容には海外旅行傷害保険が自動的に付帯されています。この 保険への加入を放棄し、総費用に含まれている保険料の払い戻しをご希望の場合は、下記および別紙にご自身で加入した保険 会社の情報を含む保険内容の詳細をご記入いただき、 EF にご提出いただきますようお願いいたします。ご自身で加入される保 険は、病気や事故の場合の治療費や緊急帰国一時費用の補償、および第三者損害賠償責任補償が含まれている必要があります。 この保険証明書に記入およびご署名いただき、コース開始日より60日前までに EF インターナショナル・ランゲージ・キャンパ スにご提出いただきますようお願い致します。
Student information（ご参加者の情報）すべてローマ字でご記入願います。
First name: 名TARO
Last name: 姓
EF Booking number: 学生番号JPT123456
Destination: 参加校 EF New York
SHIBUYA
Insurance company information（加入する海外旅行傷害保険会社の情報）すべてローマ字でご記入願います。 Name 保険会社名 XXXX Insurance Address 住所 〇〇〇Bldg. 3F, 1-2-3 xxxx, xxxx
Telephone 電話番号xx-xxxx-xxxx
Post Code 郵便番号xxx-xxxx
Country 国名 Japan
Policy Number
City 市xxxxx
保険証券番号（お申込み前の場合はブランクで提出ください）
Emergency Assistance Agent and Emergency telephone number 保険会社緊急時連絡先電話番号 xx-xxxx-xxxx Price of Insurance 支払い済または/支払い予定保険料合計金額 〇〇〇〇 円 Note that the insurance needs to be valid worldwide and cover the student not only while in school but 24/7. If the student is extending the length of the course the Insurance needs to be extended to cover the extended period. If student elects to extend its stay with EF International Language Campuses a new Proof of Insurance needs to be issued which states the extension policy until student returns to home country. This new Proof of Insurance will be sent to EF International Language Campuses office within 24 hours of extension. 加入する保険はどの国においても有効で、在校中だけでなく24時間補償する内容である必要があります。コース期間を延長する場合、 保険期間も同様に延長しなければなりません。EFインターナショナル・ランゲージ・キャンパスでの 滞在を延長する場合、延長後の 帰国日まで保険期間が延長されたことを示す新たな保険証明書が必要です。この新しい保険証明書は、期間延長後24時間以内にEFイン ターナショナル・ランゲージ・キャンパス（現地参加中の学校オフィス）のオフィスにご提出ください。
Student/parent/legal guardian signatures I/We have read and understood the above information for the required insurance coverage. I/We also understand that meeting the stated minimum requirements (page 2) is necessary to be admitted to the school. I/We furthermore undertake and agree to pay all costs in connection with treatment, evacuation or repatriation (of our child), and to hold harmless EF International Language Campuses for any damages that I/our child may cause. I/We also understand that I/the student need/s to bring the insurance policy, and card to the school on the start date of the course. 私は、上記に記載されている、海外旅行傷害保険に必要な補償内容の条件を読んで理解しました。私はまた、規定の最低限の要件（2 ペ ージ目）を満たすことが入学の要件であることを理解します。 さらに、私（あるいは私の子供）に必要な治療、避難または帰国に関 するすべての費用を負担し、私/私の子供によるいかなる損害に対しても、EF インターナショナル・ランゲージ・キャンパスは免責である ことに同意します。私は、コース開始日に学校に保険証書を持参する必要があることについても理解しています。
Student: ご参加者のお名前
(英文ローマ字でご記入願います)
Signature 署名 (参加者ご本人の署名)
Date 日付
※ 18 歳未満の方は親または保護者名をお願い致します。
Name of Parent or guardian Signature of parent or guardian （保護者の署名）
(英文ローマ字でご記入願います) Date 日付
ご自身で加入される
EF手配保険の補償内容（参考）
保険の補償内容と保険金額 加入される保険の各保険金額をご記入ください。 項目がない場合は N/A とご記入ください。 （記入当日の為替金額をご記入ください）
in USD
Illness & Accident 疾病・傷害 Medical Expenses 疾病・傷害治療費 Emergency Home Evacuation 緊急一時帰国費用
Family Member Visit 救援者費用 Home Repatriation 遺体の本国送還 Accidental Death 傷害死亡 Accidental Disability 傷害後遺障害
Unlimited無制限
Emergency Home Evacuation 緊急一時帰国費用
Unlimited無制限
Family Member Visit 救援者費用
Unlimited無制限
Home Repatriation 遺体の本国送還
100,000
Accidental Death 傷害死亡
100,000
Accidental Disability 傷害後遺障害
Program Interruption 留学中断 unattend fee未受
Flight extra cost 飛行機代追加費用 Return flight to program 留学復帰費用
講費用
Program Interruption 留学中断
Unlimited無制限
Flight extra cost 飛行機代追加費用
2,000
Return flight to program 留学復帰費用
Personal Property 個人財産
Personal Property 個人財産 Personal Belongings 携行品 Cash 現金 Valuable Documents 重要書類
Medical Expenses 疾病・傷害治療費
Unlimited無制限
Program Interruption 留学中断 Program Interruption 留学中断
Illness & Accident 疾病・傷害
4,000
Personal Belongings 携行品
500
Cash 現金
2,000
Valuable Documents 重要書類
Delay 遅延
Delay 遅延 Baggage Delay 航空機寄託手荷物遅延 Personal Delay 特定事由による遅延
200
Baggage Delay 航空機寄託手荷物遅延
900
Personal Delay 特定事由による遅延
Liability & Legal 賠償責任
Liability & Legal 賠償責任 Third Party Liability 第三者賠償責任 Legal Expenses 法定費用
100,000
Third Party Liability 第三者賠償責任
15,000
Legal Expenses 法定費用
INTERNATIONAL LANGUAGE CAMPUSES
in USD