Health Care Plan - INSEAD - PhD Programme

HealthCare PlanINSEAD MBA& PhD studentsASFE - HEALTH INSURANCE ALL OVER THE WORLD

Other garanteesincludedScope of coverage for Emergency EvacuationThis coverage is included in the annual premium.You need prior approval from Europ Assistance in order to benefit from the followingservices (see contact numbers page 8):Assistance ServicesIllness or accident• Medical contact• Transportation• Return of accompanying person• Return to your current place of residenceDeath• Transportation of mortal remains• Return home for family members• Participation to coffin expensesTravel assistance• Advance of ball bonds• Advance of lawyer fees• Transmission of urgent messages• Sending of medicines and Travel InformationBenefits100% of chargesFirst class train ticket or tourist class airline ticketFirst class train ticket or tourist class airline ticket100% of chargesFirst class train ticket or tourist class airline ticketUp to € 2,290Up to € 15,245Up to € 3,050AD&D coverageBecause an accident can result in a lot more than just medical expenses, ASFE provides forthe payment of:• A lump-sum benefit of € 10,000 in the event of accidental death• A lump-sum benefit up to € 35,000 in the event of accidental permanent disability (with adisability rate of at least 20%)Personal civil liability coverageCoverage for personal injury or material damage up to:• € 20,000,000 for personal injury• € 8,500,000 for material damage including € 150,000 for immaterial damage• € 15,000 for material left to the trainee4 ASFE - health insurance all over the world

Premiumsin France or withextension2012 monthly premiumsIt includes health care, assistance and repatriation, AD&D and personal civil liability.Minimum length of subscription: 3 months• For training period in FranceMBA or PhD participantSpouse, child€ 46 / month€ 41 / month / beneficiary• For an extension to the Wharton (USA) or Singapore campusesStudents already covered by ASFE plan in France and intending to go to Wharton or Singaporemay request an extension.MBA or PhD participantSpouse, child€ 60.50 / month€ 54.50 / month / beneficiary• You are not covered by ASFE in Fontainebleau (France) and will join the Wharton or SingaporeprogrammesYou can apply for just the time period you will spend there.MBA or PhD participantSpouse, child€ 110 / month€ 104 / month / beneficiaryUseful tip• If you have any questions regarding the payment of your Premium, you can contact ASFE atthe Enrollment & Premium departement:Tel.: +33 (0)1 44 20 48 07Fax: +33 (0)1 44 20 48 79E-mail: admineurope@asfe-expat.com• We offer you personalized & secure online services 24/7 through our website:www.asfe-expat.comASFE - health insurance all over the world 5

Some adviceto useour services• In case of planned hospitalizationContact us at least 10 days before the hospitalization. As a result, we will deliver a pre-certificationagreement to the medical facility and send you confirmation of coverage.• In case of emergencyGo directly to the hospital, present your personalized ASFE ID card to the admission desk andrequest that they contact ASFE/Mobility Benefits by phone or email within 72 hours of admission.From this, we will send them a pre-certification agreement.• Reimbursements proceduresFor outpatient medical expenses (office visits, prescription drugs, laboratory tests, x-rays as well asdental and vision care in case of accident), you must settle fees first. In order to be reimbursed,you will need to complete the healthcare forms (feuille de soins Sécurité Sociale) given to you byyour practitioner. Then send it to us with the original settled invoices, medical report if needed,medical prescription and proof of payment. If you are prescribed drugs, stick the “vignettes”(stickers) on the healthcare form.• Avoid rejected claims – Prior ApprovalHealthcare expenses are reimbursed up to the limit of the benefits, according to reasonableand customary charges. Furthermore, we request prior approval for a series of treatments withmore than three sessions or a scheduled hospitalization. To obtain prior approval, simply sendus your treatment plan including the prescription, x-rays etc. and a detailed cost estimate. Wewill reply as soon as possible upon receipt of your complete request.Useful tip• You are free to choose your practioners or hospitals in the event of illness & accident• We suggest you keep a copy of your records• We recommend you send us your RIB or IBAN (international bank details) in order to bereimbursed by bank transfer• Our team is at your service 24/7 should your require any medical advice6 ASFE - health insurance all over the world

• In the event of a sudden and unforeseenable illness or accident away from your usual residenceFor Emergency Evacuation, Europ Assistance is there for you 24 hours a day, 7 days a week.In order to obtain assistance, please contact immediately at:Tel.: + 33 (0)1 41 85 85 85Fax: + 33 (0)1 41 85 85 71You must request prior approval. Please do not forget to give:• your full name and addressthe country and city where you arethe phone number where Europ Assistance can call you back immediately• your ASFE policy number• the Europ Assistance policy number for Insead MBA and PhD students: 17009541ASFE - health insurance all over the world 7

ContactsdetailsASFE Sales department18, rue de Courcelles75384 Paris Cedex 8FRANCETel.: +33 (0)1 44 20 48 77Fax: +33 (0)1 44 20 48 80E-mail: contact@asfe-expat.comASFE Claims departmentNORTH & SOUTH AMERICASuite 300, 999 - 8 th Street SWCalgary, Alberta T2R 1J5CANADATel.: +1 403 538 2365Fax: +1 403 265 9425E-mail: adminamerica@asfe-expat.comMIDDLE EAST & AFRICASuite 2, Level 5, Gate Precinct Building 4DIFC, PO Box 506537Dubai - UNITED ARAB EMIRATESTel.: +971 4 365 1305Fax: +971 4 363 7327E-mail: adminmea@asfe-expat.comEUROPE82, rue Villeneuve92587 Clichy cedexFRANCETel.: +33 (0)1 44 20 48 07Fax: +33 (0)1 44 20 48 79E-mail: admineurope@asfe-expat.comASIA5F, North Tower, Building 9,Lujiazui Software Park, Lane 91, E Shan Rd,Shanghai, China, 200127Tel.: +86 21 6187 0593Fax: +86 21 6160 0153E-mail: adminasia@asfe-expat.com8 ASFE - health insurance all over the world

Mr Mrs Miss Family name:First name:Date of birth: _ _/_ _/_ _ _ _ Country of birth:Nationality:Please enclose a copy of your passport or ID card & a certificate of enrollment at INSEADMailing addressTown:Country:Postal code:Personal E-mail:Telephone number:Last and first nameS SEX date of birth (DD/MM/YYYY)SpouseDependent child*_ _/_ _/_ _ _ _1 _ _/_ _/_ _ _ _2 _ _/_ _/_ _ _ _3 _ _ /_ _ /_ _ _ _* under 20 years oldYour beneficiary clauseI hereby designate as my beneficiary my living spouse unless legally separated or divorced,otherwise my living children in equal shares, otherwise my father and mother in equalshares or the survivor of them, otherwise my other heirs in equal shares.orI hereby designate as my beneficiary(ies):Name, Firstname:Name, Firstname:Name, Firstname:Name, Firstname:In (name of town/city)• I hereby mandate the ASFE to choose organizations in my best interests and act onmy behalf with them. I authorize MSH INTERNATIONAL to receive on my behalf the CFE’sreimbursement statements and be directly reimbursed by the CFE or French Social Securityfor hospitalization expenses paid for me by direct payment agreement.• I have been informed of the general and specific terms and conditions, that have valueof information guide as well as of the information note of the ASFE, and I accept them.• I have been informed that I may examine, amend or delete any personal informationthat your Company maintains on my behalf (you may exercise this right by writing to:Mobility Benefits – 18 rue de Courcelles - 75384 Paris Cedex 08), in accordance with theFrench Law of January 6, 1978, on Computerized Data and Civil Liberties.Date: _ _ /_ _ /_ _ _ _Signaturepreceded by «Read and approuved»ASFE - health insurance all over the world 9

20_ _ premiumsPlease specify the premium on a monthly basis for each person with the total sum (indicatedin the box “total premium”).Effective date of coverageDurationof the stay(months)premiumSTUDENT Spouse Child(indicate if morethan one child)TotalperFAMILYFontainebleau programFrom _ _ /_ _ /_ _ _ _ to _ _ /_ _ /_ _ _ _From _ _ /_ _ /_ _ _ _ to _ _ /_ _ /_ _ _ _(Date to Date)_ _ € _ _ _ _ € _ _ _ _ € _ _ _ _ x _ € _ _ _ _Wharton/Singapore programExtensionFrom _ _ /_ _ /_ _ _ _ to _ _ /_ _ /_ _ _ _From _ _ /_ _ /_ _ _ _ to _ _ /_ _ /_ _ _ _(Date to Date)_ _ € _ _ _ _ € _ _ _ _ € _ _ _ _ x _ € _ _ _ _Wharton/Singapore programOnlyFrom _ _ /_ _ /_ _ _ _ to _ _ /_ _ /_ _ _ _From _ _ /_ _ /_ _ _ _ to _ _ /_ _ /_ _ _ _(Date to Date)_ _€ _ _ _ _ € _ _ _ _ € _ _ _ _ x _ € _ _ _ _total premium €Premium may be paid bycheck payable to ASFE (bank account in France)orcredit card (See page 13)10 ASFE - health insurance all over the world

medicalQuestionnairePlease write in capital lettersMrs. Miss Mr.Last name:First name:Date of birth: _ _/_ _/_ _ _ _If you answer “yes” to any of the questions below, please provide all details deemed useful (dates,medical grounds, carry-over effects, therapy, duration, etc.) on the attached additional pagethat you will date, sign and send along with your application in a sealed envelope for medicalconfidentiality reasons, for the attention of the Consulting Physician.Over the past 10 years, have you been hospitalizedor undergone surgery? Yes NoAre you currently under medical supervision(therapy, medical care, prescribed medication)? Yes NoHave you ever suffered from an illness,condition or accident that required medical supervisionfor more than 30 consecutive days? Yes NoHave any of your medicalor viral tests yielded abnormal results? Yes NoI hereby testify that the foregoing declarations are accurate, complete and fair. I have beeninformed and I accept that any intentional withholding of significant information or proven falsedeclaration that might mislead the Association’s insurers may lead to the cancellation of theinsurance cover and to the reduction of benefits in accordance with the provisions of ArticlesL. 113-8 and L. 113-9 of the French Insurance Code (Code des Assurances).In (name of town/city)Date: _ _ /_ _ /_ _ _ _Insured member’s signaturepreceded by «Read and approuved»ASFE - health insurance all over the world 11

ADDITIONALMEDICAL DETAILSPlease write in capital lettersMrs. Miss Mr.Last name:First name:Date of birth: _ _/_ _/_ _ _ _If you answered “yes” to any of the questions in the medical questionnaire, please provideadditional details (dates, medical grounds, carry-over effects, therapy, duration, etc.):In (name of town/city)Date: _ _ /_ _ /_ _ _ _Insured member’s signaturepreceded by «Read and approuved»12 ASFE - health insurance all over the world

CREDIT CARD DEBIT AUTHORIZATION FORMPlease charge my insurance fee for an amount of € _ _ _ _ _ _ _ _ _ to my credit card number:Name of the credit card holder:Type of credit card: Visa Master Card American ExpressCard number: / / /Expiry date: _ _ /_ _In (name of town/city)Date: _ _ /_ _ /_ _ _ _ Signaturepreceded by «Read and approuved»ASFE - health insurance all over the world 13

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ASFE – Sales contact details• 18, rue de Courcelles - 75384 Paris Cedex 08 - FranceTel. +33 (0)1 44 20 48 77 - Fax +33 (0)1 44 20 48 80• contact@asfe-expat.comYour ASFE contactASFE - HEALTH INSURANCE ALL OVER THE WORLDWWW.ASFE_EXPAT.COMASFE-INSEAD-01/2012. MSH INTERNATIONAL, Insurance brokerage S.A. with capital of 2,500,000Head office: 18, rue de Courcelles 75384 Paris Cedex 08, FRANCE - Paris "Registre du commerces et des sociétés" no 352 807 549, ORIAS (French Insurance Intermediate registry) no 07 002 751.