Student Health Form

Student Signup IN Israel

I, the undersigned (hereinafter, “the insurance Applicant”) hereby apply to Harel Insurance company (hereinafter, “the Insurer”) to insure me based on the information provided in this Application.

Personal Details

Last Name

First Name

Gender

Name of Yeshiva/Sem/Program

Date Of Birth

Age

Passport Number

Citizenship

Date of Entry to Israel

Date Coverage in Israel

Address (in Israel)

City

Phone Number in Israel

Phone Number in Home Country

Email for receiving messages, information and promotional material.

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Billing Details

Name of Card Holder

Card Number

Valid till:

Month

Year

CVV number

Personal Effects Insurance

Would you like us to contact you regarding insuring your personal belongings while in Israel?

Pre-existing conditions:

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

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

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

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

Insurance Applicant’s Statement

1. 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.

For your Information

2. Preexisting medical condition: an insurance event, substantially caused by the normal course of a preexisting medical condition, which occurred to the Insured during the period in which a restriction applies. A restriction because of a preexisting medical condition, concerning an insured whose age at the beginning of the insurance period is:

1. Less than 65 years – Shall apply for a period not exceeding one year from the beginning of the insurance period.
2. 65 years or more – Shall apply for a period not exceeding half a year from the beginning of the insurance period.

3. This medical insurance is subject to a qualification period of 48 hours.
4. I am aware that the insurance contract shall come into force only after the Company issues a written confirmation of admission regarding the Insurance Applicant. In any case, the insurance period shall begin from the date of confirmation by the Insurer, as said above.
5. Waiver of medical confidentiality: I, the undersigned, hereby give permission to the HMO (kupat holim) and/or its medical institutions and/or the all other physicians and psychiatrists, medical institutions, and hospitals, and/or any other insurance company and/or any institution and other party, insofar as necessary in order to examine the rights and obligations according to the policy and/or for the purpose of the procedure of examining of my acceptance for the insurance requested, to provide Harel with all the information and details held by the company, without exception, in the form requested by the Requester/s, regarding my health condition, including any disease that I suffered from in the past and/or that I suffer now and/or that I will suffer in the future, and I relieve you from the duty of maintaining medical confidentiality and waive confidentiality in favor of the “Requester”. This waiver is binding of my/our estate and my legal representatives and anyone substituting for me.

I, the undersigned, hereby give Harel permission to charge the account, as the meaning of this term in the terms and conditions of joining the credit card arrangement, in NIS, in the amount equal to USD
according to the representative exchange rate of the USD on the day of charging my bank account. The charge will be made in installments of the amount listed in the list of debits to be delivered to you by Harel Insurance Company Ltd., showing my credit card number. Harel Insurance Company Ltd. will set the amounts and dates of the charges according to the payment terms of the insurance policy/policies.

This permission shall expire by my notice to Harel insurance Company Ltd. This permission shall also apply to a credit card to be issued carrying a different number in replacement of the card having the number specified on this form.

For your information, tourist insurance shall come into force on the date aforementioned, provided the Application Form and the Health Statement, completed and signed by the Insured and the employer, and this permission to charge the account, arrive at the insurer’s offices prior to the said insurance inception date and are confirmed by it and/or by specific confirmation of the Insurer. Otherwise, the insurance will come into force on the date that the above documents and this permission to charge the account arrive at the Insurer’s offices, and receive approval.

The insurer’s obligation for insurance coverage is on condition that the credit card specified above, that you hold, is valid.
In every transaction (in NIS) of more than USD 700, the insurance coverage is subject to confirmation of the said transaction by the credit card company.

I agree to the above

All of your Info