Travel Insurance - Signup Form

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The prices have changed as of sep 3rd, please email chani@egertcohen.co.il for the new prices

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


Are you a candidate for one of the following procedures:
• Surgery (except plastic surgery, skin, gynecology and ENT)
• Transplant
• Blood transfusion
• Treatments in pain clinics
• Oncology treatments


During the past six months, have you been referred for a colonoscopy (as part of regular tests), CT or MRI for medical examination or diagnosis?


In order to be able to handle your request for insurance, additional medical information is required. To do this, contact chani@egertcohen.co.il/02-6227999 ext 108. 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 *
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. $9.50 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
41-50:$0.70per day
51-60:$1.10 per day
61-75:$1.70 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 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 *