Proposal for Health Insurance
Foreigners in Israel

Step 1

Step 2

Step 3

STEP 1

The purpose for coming to Israel

Insurance applicant personal details

Gender

Insurance period requested

Address**

*Note: The requested date does not bind the Company; the effective starting date of the insurance is as noted on the Insurance Details Page. **I am aware and I agree that if I do not fill in an address, the address of the employer will serve the Company for sending notices and/or documents in any matter related to insurance.

Details of previous insurance policies

Have you ever been insured by Harel or any other insurance company?

STEP 2


General Questions

Do you or have you used drugs?

Do you drink alcoholic beverages regularly (more than 2 glasses a day)?

During the last 5 years, have you been and/or are you in the process of the following medical and/or diagnostic tests that have not yet been completed and for which there is no final diagnosis: catheterization, scans, echocardiography, MRI, CT, ultrasound (not as part of routine prenatal care), biopsy, occult blood, colonoscopy or gastroscopy? (If so, attach an updated certif icate from the attending physician regarding the reason for the tests, the results of the tests, and the final diagnosis)

Have you undergone surgery or been advised to undergo surgery in the last 5 years? Please provide details.

Have you been hospitalized in the last 5 years? Please specify the reason for hospitalization and the treatment you received.

During the past 10 years have you taken or been advised to take medication on a regular basis? Please specify the problem for which you are/were treated, the treatment, and the length of time you have been taking the medication.

Have you been diagnosed with an illness, symptom, and/or disorder related to the issues specified below:

For women:

STEP 3


Did any insurance company decline or cancel at any time you application for health insurance?

Do you agree, beyond the requirements of the law or agreement, that the information included in this document, as well as additional information about you that is or will be possessed by other companies in the Harel Group (Harel Insurance Investments and Financial Services Ltd. and its subsidiaries) will be used by the Harel Group and/or anyone on their behalf, including for any matter related to the other products and services of the companies in the Harel Group (in the field of insurance, long-term savings and finances) and in their marketing, including allowing the said companies to inform you of products and services, and also for the purpose of handling other policies and/or insurance products, long-term savings and financing that you hold, processing and storing the information, and also for additional uses associated with the above-said uses and required in order to complete them, and for other related legitimate purposes, including by means of transferring the information to third parties acting on behalf of and in the name of the Harel Group.

Details of policyholder / present employer