Travel Insurance - Signup Form

You are now on a Secure Server.

Personal Details
Last Name *
First Name *
Address (in Israel) *
City *
Phone *
Fax
Email *
Date Of Birth *
Age *
Teudat Zehut *
For non Israeli's, enter passport number  *
Travel Details
Departure Date (from Israel) *
Return Date *
Cover Details
Do you require Baggage insurance? * Yes No
Do you require baggage insurance for family members? * Yes No
Cover for Laptop
(additional $1.60 per day)?
Yes No
Cover for Cellphone
(additional $1.65 per day)?
Yes No
Do you belong to a Kupat Cholim * Yes No
Pregnancy Cover * Yes No
Pregnancy week on return date:
Chronic Conditions * Yes (Please specify) No
Chronic Conditions Detail
s:
Taking Medication * Yes (Please specify) No
Medication Details:
Hospitalized in last 6 Months * Yes (Please specify) No
Hospital Details:
Medical Evacuation
Earthquake Included
Winter sports

 

Yes. Additional $4.5 per day
Extreme sports Yes. Additional $1.00 per day
Winter/Extreme sports coverage dates From:
until:
Recommended by / Saw ad in:
Other Family Members to add to the Policy
  Name Teudat Zehut/Passport Number BirthDate
1
2
3
4
5
6
7
8
9
10
If any Family members require cover for pre existing conditions, please give details here, stating to which family member the item(s) refer to:
Billing Details
Credit Card Type *
Credit Card Number *
Expiration * /
Card Owner *
ID/Passport of card holder *