Travel Insurance - Signup Form - Egert&Cohen Insurance

Travel Details

Destination *

Departure Date (from Israel) *

Return Date *

Personal Details

First Name *

Last Name *

Gender *

Male

Female

Address (in Israel) *

City *

Cellphone *

Email *

Date of Birth *

Age *

Teudat Zehut If you are a Teudat Zehut holder, please use your Teudat Zehut only

For non Israeli's, enter passport number

Add family members to this policy request?

Name

Gender

TZ/Passport

Birth Date

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Male

Female

Do any of the family members have pre-existing conditions? If so, please give all details here, stating to which family member the item(s) refer to

Do any of the family members take medication? If so, please give all details here, stating to which family member the item(s) refer to

Health Details

Do you belong to a Kupat Cholim *

Yes No

If not, please enter the following details:
Harel policy number in Israel:

Home country:

Destination:

If you do not have an Harel policy in Israel please contact us – tali@egertcohen.co.il

Is the purpose of the trip for one or more of the travelers-to receive medical care? *

Yes No

We are unable to provide insurance cover in this case

Has one or more of the travelers been under regular medication treatment or other treatment in the last 6 months, or was it recommended that he receive medication or other treatment? *
NOTE: It is not necessary to check “yes” if the medication is for cholesterol, hypothyroidism, ADD, blood pressure, sleep disorders, hormone treatment, allergies, birth control, vitamins or food supplements

Yes No

If one or more of the following options is checked off, you will need to send your doctors report to us at tali@egertcohen.co.il and then call to confirm receipt.

Are you under or was it recommended that you receive one of the following treatments?
Dialysis
Blood transfusion
Treatment in pain clinic
Oncological treatment
Treatment following organ transplant

Have you been diagnosed with one or more of the following conditions?
Aids
Chronic liver disease
Degenerative disease
Cystic fibrosis
COPD
Heart failure

Are you currently taking medication? *

Yes (Please specify below) No
Enter medication details here: (According to the policy, you need to have coverage for worsening of pre-existing conditions. You will be charged an additional premium)

In the past 6 months, have you undergone or recommended hospitalization, surgery, catherization? *
This does not include aesthetic cosmetic, surgery performed as a hospital outpatient or surgery that does not require hospitalization?

Yes No

Did the hospitalization/surgery/catheterization take place during the past three months or was it not performed?
Yes No

If you answer YES, email us an updated certificate from the attending physician regarding the surgery, hospitalization/catheterization that you were advised to undergo, and regarding your current health and functional condition in this respect.
If you answered NO, you must purchase a rider for worsening of preexisting medical conditions

Have you been referred during the past 6 months to one or more of the following tests (not as part of routine tests) that have not been completed and a final diagnosis has not yet been determined: MRI, CT, colonoscopy, ultrasound, echocardiogram, carotid doppler test, stress test, Holter monitor *

Yes No

If you answered YES, you will need to send your doctors report to us at tali@egertcohen.co.il and then call to confirm receipt.

Have you been diagnosed or have you undergone - *

A stroke Heart disease Constriction of carotid arteries

When was the last event and/or surgery that you underwent due to this problem?
During the past 12 months More than 12 months ago
If you answered that it was during the past year, send us an updated certificate from the attending physician regarding your updated medical condition: diagnosis, medications, treatments and monitoring
If you answered that it was more than a year ago, you must purchase a rider for worsening of a previous medical condition

Are you currently pregnant? *

Yes No

Is the pregnancy high risk? If so, we cannot provide insurance for your trip.

Yes No

We unfortunately cannot cover high-risk pregnancies under this policy.

Pregnancy week on date of departure:

Pregnancy week on date of return: We cannot provide insurance beyond week 32

Cover Details

Baggage insurance - $0.36/day? *

Yes No

Baggage insurance for family members? *

Yes No

Cover for Laptop (loss or theft) - $2/day?*

Yes No

Please provide the following details:
Serial, manufacturer, year

Cover for Cellphone (loss or theft) - $1.60/day?*

Yes No

Please provide the following details:
Model of phone, Manufacturer, Phone number

Medical Evacuation: Included
Earthquake: Included

Winter sports cover. $7.00 per day

Winter sports coverage dates

From:

Till:

Search and Rescue - 0.15$ per day

Extreme sports cover. $1.00 per day

Extreme sports coverage dates

From:

Till:

Regular trip cancellation due to medical reasons/death in close family (with a limited cover for Corona)?*

Yes No

Costs by age:

0-17: $0.30 per day

18-40: $0.35 per day

41-50: $0.70 per day

51-60: $1.10 per day

61-70: $1.50 per day

71-75: $1.70 per day

76-85: $2.55 per day

86-95: $3.85 per day

Trip cancellation with an extended coverage for Corona (up to $5000)? Additional $3.50 a day from ages 0-95 *

This covers cancellation due to:
Having Corona symptoms before the flight; Testing positive before the flight; Coverage for extending or shortening the trip due Corona or Corona symptoms. There is NO COVER for cancellation due to going into bidud

Yes No

Recommended by / Saw ad in:

Billing Details

Credit Card Number *

Credit Card Expiration *

Card Owner *

CVV *

ID/Passport of card holder *

Card holder's date of birth *

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