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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

First Name

Last Name

Gender

Name of Yeshiva/Sem/Program

Date of Birth

Age

Passport Number

Citizenship

Date of Entry to Israel

Start Coverage in Israel

End Coverage in Israel

Address In Israel

City

Phone Number in Israel

Phone Number in Home Country

Email Email for receiving messages, information and promotional material.

Policy Length

Pre-existing conditions:

For an additional premium of $350, we can provide cover for pre-existing or chronic conditions. Contact us for further details.

Yes

Comments / pre-existing condition details

Parental Permission

I give permission for such diagnostic, therapeutic or emergency operative procedure as may be necessary to evaluate and treat -

Name of Student

Parent/Guardian Name

Relationship

I agree

HIPAA consent

I agree to waive my HIPAA (Health Insurance Portability and Accountability Act of 1996) rights, Israel’s patient privacy laws and all other applicable privacy provisions under the law, in order to allow the Harel Insurance Company medical providers , Egert and Cohen, EMA Care medical providers to communicate with myself, each other, healthcare providers, parents, and school administrators regarding my/ my childs health condition/s .This communication can be applicable via phone, email, WhatsApp, Skype, internet-based application or other forms of communication.

If student is under 18:

On behalf of my child

Consent of parent/guardian

I agree

CTAS

TOURIST

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