Tourist Health Insurance - Form - ברק פלוס

Tourist Health Policy Sign Up

Tourist Health
Policy Sign Up

First Name

Last Name

Gender

Male Female

Date Of Birth

Age

Passport Number

Country Of Passport

citizenship

Date Of Entry Israel

Purpose Of Visit

Start Coverage in Israel

End Coverage in Israel

Street

House no.

Apartment no.

City

Zip

Mobile Phone Number in Israel

Phone Number at Home

Was the reason for coming to Israel for any of the insured to obtain medical care?

Yes No

Part A: Have you been diagnosed with an illness, condition, or disorder related to one or more of the issues specified below:

1. Stroke, Epilepsy, Multiple sclerosis, Muscular dystrophy or another degenerative disease, Headaches, Migraine, Recurring dizziness, Balance disorders, Fainting, Parkinson’s, Alzheimer’s Mental retardation, Autism, Down’s syndrome*, Cerebral palsy, Polio, Gaucher disease, Loss of sensation, Attention deficit disorder, Have you seen a doctor for complaints related to loss of memory in the last 3 years? Another problem with the nervous system

Yes No

2. AIDS and/or HIV carrier, Lupus

Yes No

3. Eyes and vision: Cataract, Retinal problems, Corneal problems, Glaucoma, Eye inflammations, Strabismus, Blindness, Other eye disease/problem

Yes No

4. Heart: Arrhythmia, Cardiac defects, Heart failure, Heart attack, Congenital heart defect, Catheterization or bypass surgery, Vascular diseases, Other heart disease/problem

Yes No

5. Blood vessels: Varices in veins of leg, Carotid artery stenosis, Clotting disorders, Anemia Blood disease, DVT (thrombosis), PVD (peripheral vascular disease)

Yes No

6. Metabolism: Thyroid gland, Lymph gland, Salivary gland, Sweat gland, Pituitary gland, Diabetes, Hypertension, High fat/cholesterol, Other metabolic disease/problem

Yes No

7. Respiratory: Asthma Tuberculosis in past with full recovery, Active tuberculosis at present, COPD (chronic symptomatic lung disease), Hay fever, Recurrent infection of respiratory airways and shortness of breath, Pneumothorax, Cystic fibrosis, Other disease/problem of respiratory airways

Yes No

8. Digestive system: Ulcer (stomach or duodenum) Heartburn, Crohn’s disease, Colitis, Reflux Hemorrhoids, Fissure/Fistula, Intestinal blockage, Pancreatic diseases/infections Esophagus, Gall bladder, Gall stones, Other disease/problem of the digestive system?

Yes No

9. Liver: Hepatitis B, C, D Hepatitis A, Fatty liver, Cirrhosis, Other liver disease/problem

Yes No

10. Hernia: In diaphragm, In umbilicus, In right groin, In left groin, At site of surgical scar, In abdominal wall

Yes No

11. Kidneys and urinary tract: Recurring infections, stones in kidneys or urinary tract, Cysts in kidneys, Defects in urinary tract, Renal failure, Other disease/problem of kidneys and urinary tract

Yes No

12. Joints and bones: Arthritis Gout Back/spine Knees Thighs, Shoulders Joints Decline in bone density, Other disease/problem of joints and bones

Yes No

13. Skin and Sex: Skin tumors, Skin damage, Psoriasis, Sexual diseases, Syphilis, Other skin disease/problem, Other sexual disease

Yes No

14. Malignant tumors*/ Malignant diseases (cancer) – if yes, is the disease or tumor active and/or diagnosed and/or treated in the past two years?

Yes No

15. For women: Benign breast cysts or tumor, Breast augmentation, Fibrocystic breasts, Benign uterine cyst/tumor, Uterine fibroids, Endometriosis, Uterine bleeding, Cervical diseases (CIN), Benign ovarian cyst/tumor, Polycystic ovaries, Benign cyst/tumor in Fallopian tubes, Recurring miscarriages, Ectopic pregnancy, Have you undergone childbirth by Caesarian section? Are you pregnant? Other problem with gynecological system or breasts?

Yes No

16. For men: Prostate problems, Varicocele, Hydrocele, Other men’s disease/problem

Yes No

17. Mental illnesses diagnosed by a psychologist, psychiatrist, or family physician: Depression, Anxiety, Other mental illness

Yes No

18. Ear, nose and throat: Sleep apnea, Polyp in nose Sinusitis, Recurring throat infections, Vocal cord nodules, Adenoid Enlarged nasal concha, Snoring, Deviated septum, Hearing impairment/deafness, Acoustic neuroma (tumor in auditory canal), Torn eardrum, Tinnitus, Other ear-nose-throat disease/problem

Yes No

19. Have you been diagnosed as suffering allergies?

Yes No

Part B: General Questions

20. Do you use or have you used drugs? If yes – Cannabis/Other drug

Yes No

21. Do you or have you regularly drunk alcoholic beverages, in a quantity of more than 2 glass a day?

Yes No

22. Have you been referred for and not yet completed a, process of investigation of a phenomenon or disease in, the past two years for which no final diagnosis has been, determined? (type of tests: mammogram, bone scan, catheterization, heart scan, echocardiogram, CT, MRI, ultrasound – not as part of prenatal monitoring, biopsy, occult blood, colonoscopy, gastroscopy, colposcopy

Yes No

23. Have you undergone surgery in the past 5 years or has it been recommended that you undergo surgery/transplant due to a disease/phenomenon/problem that you did not specify in one of the previous questions?

Yes No

24. Have you been hospitalized in the past 3 years due to a disease/phenomenon/problem that you did not specify, in one of the previous questions?

Yes No

25. Have you taken medication or been recommended, to take medication in the past 5 years for a disease/, phenomenon/problem that you did not specify in one, of the previous questions?

Yes No

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.

e. This consent and statement, including the Health Statement above, shall also apply to the children whose names are listed in the Application and your signature/s on the documents is made also in their names as their guardian. Are you authorized to sign these documents on their behalf?

f. I hereby confirm that I received essential information regarding the insurance, which included, at the very least, a description of the main elements of the coverage, the insurance premium, the insurance period, the main insurance amounts and the main limitations of liability, and regarding my possibility of obtaining full details about them.

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. Consent to Use of Information I agree, beyond the requirements arising from the law or an agreement, that the information included in this document, as well as additional information about me that is held or will be held by other companies in the Harel Group (Harel Insurance Investments and Financial Services Ltd. and its subsidiaries) will also serve the companies in the Harel Group and/or parties on their behalf for any purpose related to the other products and services of the companies in the Harel Group (in the area of insurance, long-term savings and finances) and its business partners and in their marketing, including to enable said companies to notify me of information about products and services, and for additional uses that accompany the above-said uses and are necessary to complete them, this also by means of providing the information to third parties that act in the name of and on behalf of the Harel Group.

6. Waiver of medical confidentiality: I/we the undersigned hereby give permission to an HMO (kupat holim) and/or its medical institutions and/or the IDF, and all the physicians and/or psychiatrists, the other medical institutions and hospitals, the National Security Council (MALAL) and/or the Ministry of Defense and/or any insurance company and/or to any other institution and entity, insofar as required in order to inquire and settle claims according to the policy and/or for the purpose of the procedure for examining my acceptance to the requested insurance plan to provide Harel including any information held by the Company and details with no exception and in the form required by those requesting it, about my/our health condition, about any illness I/we had in the past and/or that I/we are ill with now and/or will be ill with in the future and I/we release you from the duty of maintaining medical confidentiality and waiver this confidentiality towards the "requestor." This waiver binds me/us, my/our estate and my/our legal representatives and anyone that appears in my/our place. This waiver will also apply to my/our minor children.

7. By enrolling in this policy, you are authorizing your insurance agent in the policy to submit and to receive on your behalf/and for you all notices and/or documents related to the underwriting and policy enrolment processes

I agree to the above.

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