Travel insurance attest

Travel insurance attest
What is the purpose of a travel insurance certificate?
If you are traveling outside the European Union and the destination country requires a visa to enter, you may be required to provide a travel insurance certificate to complete your visa application.

If you travel to a European Country, there is no need to request a travel insurance attest
Date of request

DayMonthYear
Date
Why do you need a travel insurance attest ?*
If other, please specify here*
In this form, you are able to request a travel insurance attest. List here all the travelers.

We will verify those informations with Qonto prior to delivering this attest.

This process takes about 1 week to be performed.
This travel attest are reserved to Qonto customer owner of a "Plus" card or an "X" card*

I confirm that I own such card at Qonto

List of travelers
The following persons are considered as insured by the Qonto insurance program :

-"Plus" or "X" cardholder

-his/her spouse

-their unmarried children and grandchildren under the age of 25

-their fiscally dependent ascendants

All other persons travelling with you will not be covered and can not figure in this travel insurance attest.
How many traveler in total are "insured" as per the above definition ?*
Cardholder's name*

First NameLast Name
Cardholder's email*
example@example.com
IBAN of your Qonto account*
Provide here your bank account number in IBAN format
Traveler 2

First NameLast Name
Traveler 2 relation to cardholder
any other relation to the cardholder is not insured and will not figure on the travel attest
Proof of relation of traveler 2 to cardholder

An official document, a tax document or an honor attest worth as proof of the relationship
Cancelof
Traveler 3

First NameLast Name
Traveler 3 relation to cardholder
any other relation to the cardholder is not insured and will not figure on the travel attest
Proof of relation of traveler 3 to cardholder

An official document, a tax document or an honor attest worth as proof of the relationship
Cancelof
Traveler 4

First NameLast Name
Traveler 4 relation to cardholder
any other relation to the cardholder is not insured and will not figure on the travel attest
Proof of relation of traveler 4 to cardholder

An official document, a tax document or an honor attest worth as proof of the relationship
Cancelof
Traveler 5

First NameLast Name
Traveler 5 relation to cardholder
any other relation to the cardholder is not insured and will not figure on the travel attest
Proof of relation of traveler 5 to cardholder

An official document, a tax document or an honor attest worth as proof of the relationship
Cancelof
Traveler 6

First NameLast Name
Traveler 6 relation to cardholder
any other relation to the cardholder is not insured and will not figure on the travel attest
Proof of relation of traveler 6 to cardholder

An official document, a tax document or an honor attest worth as proof of the relationship
Cancelof
Destination
Country*
First day of the travel in that country*

DayMonthYear
Date
Last day of the travel in that country*

DayMonthYear
Date
Travel duration (days)
The destination of your travel is not included in the list of covered destination. This trip is not eligible for the travel insurance of your card. We can thus not deliver a travel attest.

We advise you to subscribe a dedicated travel insurance at another insurer
The duration of your travel is below 0 days or longer that 90 days. This trip is not eligible for the travel insurance of your card. We can thus not deliver a travel attest.

We advise you to subscribe a dedicated travel insurance at another insurer
Should be Empty:

Travel insurance attest

List of travelers

Destination