The insurance attachment organizes the information from the insurance policy attached to the residence card application. However, it should not include any new information or replace documents issued by the insurer. Below you will find a template that you can fill out based on your own insurance policy.
This is not an official form nor a promise that the same arrangement will be adopted in every case.
Before submitting your documents, check the current guidelines from the relevant agency and the contents of the notice, if you have received one. The most important rule is simple: Do not copy data from memory. The insurer's name, policy number, the insured person's information, and the coverage period should match those in the source document. This ensures that the attachment serves as a clear explanation rather than creating discrepancies.
What Does the Insurance Attachment Cover?
The attachment provides a brief description of the information shown on the policy. Its value is compliance with the policy, rather than a detailed form. You can use it to record basic identifying information, the document number, the coverage period, and the insurer’s name. If the policy contains other relevant details, they should be transcribed while preserving their original meaning.
Do not present your own attachment as a document issued by the insurer. Also, do not refer to it as an official form. Before using this template, check whether the relevant agency specifies its own form or list of documents for your case. That is why the template below leaves space for information from a specific document and for a personalized statement of purpose.
The appendix is not intended to describe the entire residency situation. It is meant to provide a consistent dataset along with the policy and other documents. The broader context is discussed in the guide on insurance under the laws governing foreigners. However, the article itself does not specify which documents are required in individual proceedings.
How to Prepare Data Before Filling Out the Form
Start by opening the current policy. If you have multiple versions of the document, use the one that corresponds to the period covered by the case. Do not combine data from different policies, and do not correct the names listed in the document on your own. Do not add benefits, which are not covered by their policy.
Prepare:
If the insurance is to cover more than one person, don't assume that a single piece of information automatically applies to all family members. Compare the list of people with the document. A separate guide on Family Insurance with a Residence Card.
Before filling out the form, be sure to read the policy and its terms and conditions. Information on how to evaluate the amount and scope of insurance coverage for the residence card, will help distinguish identifying information from the description of the protection. The annex should not broaden the scope of the agreement through paraphrasing.
Working template for the appendix
Copy the template below into your text editor and replace the square brackets with the information from your own policy. Delete any fields that are not included in your document. Do not enter sample values just to fill in every line.
Information Statement Regarding Insurance
I, [first and last name], am providing the following information based on the attached insurance policy for the insured person:
I hereby declare that I have copied the above information from the attached insurance document.
[City and date]
[A legible signature, if required for the submitted version of the document]
This template intentionally does not include a statement that the policy meets all the requirements of a specific case. Nor does it include a ready-made description of the scope of benefits. Such wording could go beyond the terms of a specific contract. If you need a basic explanation of the product, please refer to the guide on Insurance for Foreigners in Poland.
How to Check the Policy Attachment and Coverage
First, compare each line with the policy. Check character-by-character matching the document number and the spelling of the first and last names. Please note that dates of protection – The date the attachment was prepared is not the same as the period specified in the contract. Also, be sure to document name exactly as it appears in the source material.
Next, check to see if the text says more than the policy does. Draft template does not meet the agency's requirements, does not replace an insurance policy i does not promise approval documents. If the agency has issued an individual request, compare the set of materials you are preparing with that request, rather than treating this template as a response to every possible request.
It is important to distinguish between the document filed in the case and the actual scope of coverage. According to Compensa’s General Terms and Conditions of Insurance from 2026, KLC coverage includes medically necessary costs of treatment for an illness or the consequences of an accident, provided that the insured person must undergo such treatment immediately while staying in Poland. As part of this coverage, Compensa arranges medical assistance and covers its costs until the insured’s health permits a return or transport to their country of permanent residence. This information pertains to a specific product and document, not a general description of every policy.
After filing a claim, Compensa may ask for medical or rehabilitation records in the event of personal injury. It may also demand invoices and cost estimates regarding costs incurred for medical treatment, the purchase of medications, dressings, and medical aids, or their repairs. This portion of the documentation pertains to the handling of the claim in accordance with the terms and conditions set forth in the General Terms and Conditions; it should not be automatically included in the list of attachments for the residency proceedings.
Finally, read the finished text without looking at the template. It should be understandable on its own. During the final check, place the policy and the completed attachment side by side. Read the fields in the same order, and after checking each one, mark them on your working copy. Separately, compare the spelling of the first and last name, the policy number, the insurer’s name, the product or plan name, and both dates of coverage. Also check whether all square brackets have been replaced or removed and whether the list of attached documents matches what is actually included in the set. If you notice a discrepancy, refer back to the source document instead of correcting the content from memory. Only after making this comparison should you prepare a clean version of the attachment. Save a copy of the submitted version along with the source document, so that you can later determine what data was presented.
Frequently Asked Questions
Is this template an official form?
No. This is a working template designed to help you transcribe and organize the information from your own policy. There is no basis for presenting it as a single, mandatory template for all government agencies and all types of proceedings.
Can an attachment replace a policy?
No. The attachment describes the information contained in the document, but it is not a document issued by the insurer. The content of the attachment and the policy must be consistent, and the scope of the materials to be submitted must be determined on a case-by-case basis.
Is it necessary to list the scope of all services?
It is not worth creating your own list of benefits. If you need to provide information about coverage, copy it from the relevant document without expanding on its meaning. Detailed statements about the product should be based on the applicable insurance terms and conditions.
What should you do if the information on your policy is out of date?
Do not correct them yourself in the attachment as if the change had been made in the source document. First, clarify the discrepancy in a manner appropriate to the policy, and only then prepare a consistent set of documents. Your own annotation does not alter the content of the insurance document.
Where can I find more information about insurance in the context of a residence card?
Start by reading the material on insurance under the laws governing foreigners, and then compare its description with the terms of your own policy and the information you received regarding that specific case. Do not automatically copy information from other people’s documents.
What to Do Next
First, fill out the form based on your existing policy and remove any unused fields. Then, carefully check the document number, the insured person’s information, and the coverage period. If you’re just starting to choose KLC insurance, use the calculator available at insurancepoland.pl. This tool is designed to calculate your premium, not to confirm the requirements for a specific procedure.
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