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Personal Details

First Name *

Last Name *

Gender *

Male

Female

Date of Birth *

Age *

Passport Number *

Country of Passport *

Citizenship *

Date of Entry to Israel *

Purpose of Visit *

Start Coverage in Israel (dd/mm/yyyy) *

End Coverage in Israel (dd/mm/yyyy) *

Address where you are staying in Israel:

Street *

House no. *

Apartment no.

City *

ZIP

Mobile Phone Number in Israel *

Email * Email for personal notifications and mailings.

Phone Number at Home *

Emergency Medical Evacuation to Home Country: 1.75 NIS/day *
Subject to approval of Harel and a physician on their behalf. Coverage is up to 35,000 NIS

Yes

Provider Selection: *

Harel

Maccabi Health Services (HMO)

Clalit Health Services (HMO)

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Personal Details

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