Are you travelling with Brithright/Taglit?

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Please signup within a month of your trip

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Primary Policy Holder Details
Last Name *
First Name *
Date of Birth * / /
Age  *
Passport Number *
Gender * Male Female
Are you suffering from or have you ever suffered from,  or have you been diagnosed with any of the following *
 *
 

Details (please add date of event):
I am coming on a ... * Private Tour
Group Tour (name):
Home Address *
City *
ZIP
State
Country *
Phone in the US *
Fax
Email *
Name of the owner of the credit card you will be using  *
Travel Details
Start Date *
End Date *
Health Details - for the current family member
Have you ever been insured by Harel? * No Yes
Has Harel or another insurer refused to insure you ? If yes, specify which company and for what reason ? * No Yes
Details:
Are you pregnant? * No Yes
Are you sick now? * No Yes
Details:
How did you hear about us?

Renunciation of Medical Secrecy
I, hereby give my permission to all the doctors and other medical institutions and hospitals and/or to all insurance companies and/or to every institution and other body or individual, to provide Harel Insurance Company Ltd.  with all the details, without exception and in the matter that shall be demanded by Harel, as regards my state of health and/or any disease that I have suffered from in the past and/or that I am currently suffering from, and I hereby release you from the obligation to safeguard medical secrets and hereby renounce this secrecy towards Harel. This declaration of renunciation binds me, my estate and my legal delegates and everyone who will come in my stead. This declaration of renunciation shall also apply to the minors in this policy.



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What is a pre-existing condition?

Cover: Sudden deterioration of pre-existing illness/medical condition where:
1) Condition has been stable for 18 months prior to arrival.
2) Accident-no hospitalization for 6 months prior to arrival.
Excluded: Transplants,M.S.,dialysis,Cystic Fibrosis,sexual diseases,active psychiatric conditions, cancer treatment.