Travel Insurance - Signup Form

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For a quote, please call Tali on: 02-622-7999 (ext. 125)

In the past six months or currently up to the date of departure, have you been diagnosed with a medical condition which requires one of the following:
• Treatment (medication or other)
• Medical Supervision (which is not part of routine tests)
• Hospitalization


If you answered 'yes', it's advised to purchase coverage for a pre-existing condition.

Are you a candidate for one of the following procedures:
• Operation (excluding cosmetic surgery, skin, gynaecological procedure, ENT)
• Transplant
• Blood transfusion
• Pain clinic
• Oncological treatments


If so please provide us with a current medical report.

During the past six months, have you been referred for a colonoscopy (not as part of regular tests), CT or MRI for medical examination or diagnosis?


If you answered 'yes', it's advised to purchase coverage for a pre-existing condition.

Are you Pregnant?

In order to be able to handle your request for insurance, additional medical information is required. To do this, contact tali@egertcohen.co.il/02-6227999 ext 125. You must obtain a Medical report from the treating physician regarding the problem, the method of treatment and the current situation.)

Personal Details
Last Name *
First Name *
Gender *
Address (in Israel) *
City *
Phone *
Fax
Email *
Date Of Birth *
Age *
Teudat Zehut *
For non Israeli's, enter passport number  *
Travel Details
Destination  *
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 (loss or theft)
($2 per day)?
Yes No
Cover for Cellphone (loss or theft)
($1.60 per day)?
Yes No
Do you belong to a Kupat Cholim * Yes No
Are you currently pregnant? * Yes No
Is the pregnancy high risk? Yes No
Pregnancy week on date of departure:

Pregnancy week on date of return:
Are you currently taking medication?  * Yes (Please specify) No
Medication Details:
Medical Evacuation
Earthquake Included
Winter sports

 

Yes. $7.00 per day
Extreme sports Yes. $1.00 per day
Winter/Extreme sports coverage dates From:
until:
Trip cancelation due to medical reasons? Yes No

Costs:
0-17: $0.30 per day
18-40:$0.35 per day
41-75: $0.50 per day
76-85:$2.15 per day
86-95:$3.20 per day
Recommended by / Saw ad in:
Other Family Members to add to the Policy
  Name Gender 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 *
CVV *
ID/Passport of card holder *