Travel Insurance - Signup Form

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

Are you a return customer who has signed up with us for Travel Insurance before?

If so, save time filling out the form by entering your cell and te'udat zehut
Note, these must be the details you used when signing up previously
:
Personal Details
Last Name *
First Name *
Gender *
Address (in Israel) *
City *
Cell 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 *
Health Details
Do you belong to a Kupat Cholim * Yes No
Is the purpose of the trip for one or more of the travelers-to receive medical care?  * Yes No

We are unable to provide insurance cover in this case
Has one or more of the travelers been under regular medication treatment or other treatment in the last 6 months, or was it recommended that he receive medication or other treatment?  *
NOTE: It is not necessary to check “yes” if the medication is for cholesterol, hypothyroidism, ADD, blood pressure, sleep disorders, hormone treatment, allergies, birth control, vitamins or food supplements
Yes No
If one or more of the following options is checked off, you will need to send your doctors report to us at tali@egertcohen.co.il and then call to confirm receipt.

Are you under or was it recommended that you receive one of the following treatments?






Have you been diagnosed with one or more of the following conditions?






Are you currently taking medication?  * Yes (Please specify) No
Medication Details:
In the past 6 months, have you undergone or recommended hospitalization, surgery, catherization? *
This does not include esthetic cosmetic, surgery performed as a hospital outpatient or surgery that does not require hospitalization?
Yes No
Did the hospitalization/surgery/catheterization take place during the past three months or was it not performed?
Yes No

If you answer YES, email us an updated certificate from the attending physician regarding the surgery, hospitalization/catheterization that you were advised to undergo, and regarding your current health and functional condition in this respect.
If you answered NO, you must purchase a rider for worsening of preexisting medical conditions
Have you been referred during the past 6 months to one or more of the following tests (not as part of routine tests) that have not been completed and a final diagnosis has not yet been determined: MRI, CT, colonoscopy, ultrasound, echocardiogram, carotid doppler test, stress test, Holter monitor * Yes No
If you answered YES, you will need to send your doctors report to us at tali@egertcohen.co.il and then call to confirm receipt.
Have you been diagnosed or have you undergone? *



When was the last event and/or surgery that you underwent due to this problem?



If you answered that it was during the past year, send us an updated certificate from the attending physician regarding your updated medical condition: diagnosis, medications, treatments and monitoring
If you answered that it was more than a year ago, you must purchase a rider for worsening of a previous medical condition
Are you currently pregnant? * Yes No
Is the pregnancy high risk? Yes No

We unfortunately cannot cover high-risk pregnancies under this policy.
Pregnancy week on date of departure:

Pregnancy week on date of return:
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
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 cancellation 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 *