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SASSON CHACOTY Insurance Agency
King George Street 25, Jerusalem, Israel
P.O.B 2 4 2 4 Zip Code No. 91023
Phone 972-2-6254488 Fax 972-2-6251276
info@chacoty.co.il |
Application Form tour &
CareTo print this form please
click
here and then print the page To Pay by Credit Card, please
click
here and then print the page A. Member’s Personal Details |
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| Last
name |
First name |
Passport number |
Institute: |
Date of Birth: (In the dd MMM yyyy format.
Spaces separate the values. Examples: 31 January 2003 or
29 March 2004 or 29 Feb 2008) |
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Address In Israel |
Street |
Number |
Town |
Telephone |
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Home Address |
Street |
Number |
Town |
Country |
Telephone |
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E-Mail |
Period of Insurance |
From: (In the dd MMM
yyyy format. Spaces separate the values. Examples: 31 January
2003 or 29 March 2004 or 29 Feb 2008) |
To: (In the
dd MMM yyyy format. Spaces separate the values. Examples:
31 January 2003 or 29 March 2004 or 29 Feb 2008) |
Total number of days insured |
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For office use only
Insured days _______ X Daily premium rate
US $ _______/day = Total Amount due US $ ______
Total premium US$ ______ X Rate of exchange _____________
= Total Amount due NIS ______
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B. Declaration of Health – Answers to these
questions are mandatory
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If you have responded “yes” to one or more of the questions,
please provide the requested details in the box on the right
(“Details”).
Write the question number, and next to it, the date of the
event referred and your present condition. Then please sign
the
declaration below and return this form.
Personal Declaration: I declare and confirm that I have
read the Terms & Condition of the policy and its exclusions
I am aware that the benefit under this policy do not
cover treatment arising from any existing diseases, injuries,
or conditions as indicated In the “yes” column for which
I have been diagnosed or which have required
medical treatment including prescription medications.
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C. Details of Insurance In your home country – please
select one
Please select one. If you know your insurance company
name, please type it in the text box
Insurance company name if you know it
D. Confirmation
Payment for the above premium amount has been received.
Once your application has been processed and approved by
Harel Insurance Co. Ltd. , the insurance coverage takes
immediate effect.
Date______________________________ Sasson Chacoty ____________________________
(authorized Signature)
E. Renunciation of Medical Secrecy
I, hereby give my permission to the Kupat Holim sick
fund and/or its medical institutions, as well as to all
the doctors and other medical institutions and hospitals
and/or to all the insurance companies and/or to every institution
and other body or individual, to provide Harel insurance
Company Ltd. (hereinafter the “requestor”) with all the
details, without exception, and in the manner that shall
be demanded by the requestor, as regards, my state of health
and/or any disease that I have suffered from in the past
and/or that I am currently suffering from and/or that I
will suffer from in the future , and I hereby release you
from the obligation to safeguard medical secrets and hereby
renounce this secrecy toward the Requestor. This Declaration
of Renunciation binds me, my estate and my legal delegates
and everyone who will come in my stead. This declaration
of renunciation shall also apply to the minors.
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