Of the President of the National Health Fund

Appendix No. 2 to Regulation No. 52/2013/DSS of the President of the National Health Fund of 19 September 2013r.

VOLUNTARY HEALTH INSURANCE AGREEMENT NO...... 1 / ...... /200.... concluded on ...... , between The National Health Fund - ...... Regional Branch with its registered office in ...... , represented by ...... , Director of the Branch and Ms/Mr ...... hereinafter referred to as “The Insured Party”

The regulations of the Act of 27 August 2004 on healthcare services financed from public funds (Dz. U. [Journal of Laws] No. 210 item 2135, as amended), hereinafter called “the Act”, provide the legal basis for this agreement.

The subject matter of this agreement is the provision of health insurance for the Insured Party, who submitted a written application for a voluntary health insurance in the extent defined in the Act. The application constitutes an integral part of the agreement.

1. The Insured Party declares that he/she is not included in any compulsory health insurance scheme pursuant to art. 66 of the Act, or in any compulsory health insurance scheme in another European Union or EFTA member State – a party to the EEA Agreement – and submits the application to include him/her in the voluntary health insurance scheme in the National Health Fund with the family members specified in the application and forms: ZUS ZCNA (registration of family members for health insurance whose address is not the same as the beneficiary's address) or ZUS ZCZA (registration of family members for health insurance who reside at the same address as the beneficiary). 2. The forms mentioned in par. 1 constitute an integral part of the agreement. The Insured Party will submit the forms and ZUS ZZA (registration form for health insurance) to the relevant branch of the Social Insurance Institution, responsible for the place of residence.

1National Health Fund branch number

§ 4 1. Pursuant to the provisions of art. 68 par. 7 and 8 of the Act, the requirement for being included in the health insurance scheme is payment to the account ...... , Regional Branch of the National Health Fund No...... , with its registered office at ...... , in the amount of PLN ...... (say: PLN ...... ), subject to art. 68 par. 9 of the Act. 2. The payment is made by the Insured Party: 1) on the day of signature of this agreement*; 2) in ...... monthly instalments in the amount of PLN ...... (say: PLN ...... ), each paid by the 10th day of the month, from the month following the month of the signature of this agreement*; 3) the National Health Fund withdraws from collecting payment*.

1. The contribution assessment basis paid by: 1) the person referred to in art. 68 is the amount of the declared monthly income, not lower than the amount equivalent to the average salary; 2) the insured referred to in art. 68 par. 2 is the amount equivalent to the average salary; 3) the person referred to in art. 3 sec. 2 points 1-4, is the amount set out in art.68 sec.4 point 3 of the Act. 2. The Insured Party revises contribution rates in accordance with the changing contribution assessment basis. 3. The contribution payment and recording are conducted through the branch of the Social Insurance Institution responsible for the place of residence. The Insured Party is obliged to pay the contributions for each month into the bank account of the Social Insurance Institution by the 15th day of the following month. 4. Failure to pay the health insurance contributions within the time limit will lead to interest being collected for late payment on terms and in the amount specified by the provisions pursuant to the Act of 29 August 1997. Tax Ordinance (Dz. U. [Journal of Laws] No.137 item 926, as amended). 5. The contribution rebate is conducted on terms specified in the Act of 13 October 1998 on the social insurance system (Dz. U. [Journal of Laws] No. 137 item 887, as amended).

1. The Insured Party is included in the health insurance scheme from ...... till the date of the termination of the agreement or after a month of perpetual default in covering contributions, 2. Including in the health insurance scheme the person referred to in clause 1 means within the meaning of art. 5 point 3 and art. 3 par. 2 points 5 and 6 of the Act, at the same time coverage under the insurance of his/her family members referred to in the forms specified in § 3.

§ 7 The entitlement to health benefits of the Insured Party and his/her family members commences on the date of the coverage under the insurance specified in § 6 par. 1 and expires after 30 days from the date of termination of the insurance in the National Health Fund.

This agreement, together with evidence of paid contribution for the previous month, constitute the evidence of the insurance within the meaning of art. 240.

1. The agreement is concluded for a unspecified period of time. The agreement can be terminated by the Insured Party through the submission to the National Health Fund of a written statement on resigning from the voluntary health insurance. 2. The agreement expires after a month of perpetual default in covering contributions or in the case of failure to pay the next instalment within the time limit. 3. The agreement also expires in cases provided for in separate regulations, including the regulation on coordination, especially: 1) on the decision of the Director of the Regional Fund Branch, relevant laws of another European Union or EFTA member State – a party to the EEA Agreement; 2) upon a change in the Insured Party’s place of the residence outside the territory of the Republic of Poland.

To all matters not settled herein, the provisions of the Civil Code and the Act of 27 August 2004 on healthcare services financed from public funds (Dz. U. [Journal of Laws] of 2008 No. 164, item 1027, as amended) shall apply.

Any disputes arising in the course of the performance of the agreement shall be resolved by the court of law responsible for the address of the registered office of the National Health Fund branch.

This agreement was executed in two identical counterparts, one for each party.

INSURED PARTY NATIONAL HEALTH FUND