___________________________

Name of medical insuranceor ganisation

is entitled to be rendered medical aid according to the contract of a compulsory medical insurance No. _____ dated _____ effective from _____ to _____ according to compulsory medical insurance programme approved. The programme and list of medical institutions enclosed.

1. The Insurer effects payment of medical and other services rendered the citizens included by the Insurant into lists [enclosed]. Each insured person is provided with the insurance policy of a certain form.
2. The volume of services is determined by the programme of the compulsory medical insurance. The programme and list of medical institutions engaged with such services are considered an integral part of the present Contract.
3. The Insurance is obliged to pay compulsory insurance premiums for employed within the term stipulated by the present Contract.
4. Total number of the insured persons at the moment of the conclusion of the present Contract is _____.
5. The Insurant is to provide the Insurer with the list of the insured persons within _____ days from the date of the conclusion of the present Contract [with the distribution in groups if necessary]. The list of the insured persons should contain names and surnames of them as well as dates of birth, sex, workplace, place of residence.
6. In case of change in number of the insured persons the Insurant is obliged to inform the Insurer about it for the further re-drawing of the policies.
7. The Insurance is to submit to the Insurer information about the health of the persons subject to insurance in this territory or enterprise.

1. The amount of the insurance premium for each insured person is _____ roubles a year.
2. Insurance premiums are to be paid by the Insurant _____ days before _____. Insurance premiums are to be paid _____ [Method of payment].
3. The present Contract comes into force _____.
4. In case of change in number of the insured persons the Insurant is to make fresh account with the Insurer.
5. The amount of the insurance premium can be reduced in case of stable level of sickness rate of the employed or its decrease.

The present Contract is concluded for the time period from _____ to _____. Should neither side inform about the cessation of the Contract not later than _____ it is prolonged for the time period of _____.

1. In case of the delay in premium payment the Insurant is to pay the Insurer a penalty at the rate of _____% of the delayed payment for each day of delay. However the payment of the penalty does not release the Insurant from the premium payment.

• After _____ days of delay the Insurer is entitled to cease the Contract with due notification of the Insurant.
  
• After the Insurant effects payment of debts and penalty the Contract is resumed.
  
• The charges of the Insurer connected with the notification of medical institution about the cessation and resumption of the Contract are to be compensated by the Insurant.
  

1. Should medical insurance institution refuse the services stipulated in the policy to the insured person or in case of incomplete or unsatisfactory services the Insurer can be applied sanctions as follows:

• - reimburse to the Insurant _____% of the premium
• - penalty _____ roubles [or forfeit at the rate of _____% of the premium].
  

All disputes and discords arising in connection with the present Contract are to be settled in the Court.

Addresses and accounts of the both sides:

Enclosure:

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INSURER INSURANT

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