Lev HaTorah Shana Bet - CHAI Student Health Policy Sign Up

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I the undersigned (hereinafter, the "insurance applicant") ask of "Harel" Insurance Company Ltd. (hereinafter, the "Insurer") to insure me, based on all the contact of this Application.

Personal Details

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Health Statement

Have you been diagnosed with a disease, syndrome, disorder related to one or more of the issues listed below:

The Nervous system (neurology) and the brain:

The respiratory system:

Immune system diseases:

If the answer to any of the questions above is "Yes", you must send an up-to-date report from the attending physician regarding the stated problem, test results, the manner of the treatment and the current condition to Tzippy: health@egertcohen.co.il.

Pre-existing conditions:

For an additional premium of $150, we can provide cover for pre-existing or chronic conditions. Contact us for further details.

Please review the statement below and then proceed to submit the form below

Insurance Applicant’s Statement

a.       The information included in this document is required for your joining the policies and for all other matters and issues pertaining to the policies and the handling thereof. The Company and other companies of the Harel Group (Harel Insurance Investments and Financial Services Ltd. and its subsidiaries) and/or anyone on their behalf will make use of it, including the processing, storage and use thereof, for any matter pertaining to the policies and for other legitimate purposes, including by providing the information to third parties acting in the name and on behalf of the Harel Group.
b.        I/we hereby declare that all the answers are correct and complete and are provided out of my/our own free will.
c.         The answers specified in the Health Statement and any other information to be submitted to the Company as well as the Company’s customarily prevailing terms and conditions in this matter shall be essential terms, conditions of the insurance contract between you and the Company, and constitute an inseparable part thereof.
d.        The Company may decide to either accept or reject the Application. For your information, the insurance contract shall come into force only after the Company issues a written confirmation of admission of all the insurance applicants.