A. Personal Details
* Student No:
 
*Last Name:
 
*First Name:
 
* Date of Birth:
      day/month/year
*Passport/I.D. No.
 
Gender:
Address in Israel
Street:
Number:
Town:
Zip Code:
 
Telephone:
Home Address:
*Country:
 
State/Province:
*Street:
 
*Number:
 
*City:
 
Zip Code:
 
*Telephone:
 
country code + city/area code + number
*Email:
 
B. Declaration of Health
Please answer the following yes/no questions by checking the appropriate box and provide any relevent details in the section below.
Questions No / Yes
1. Have you been hospitalized at any time? If so, when and for what reason?  
2. Have you suffered or are you suffering now from: heart disease, cancer, cerebral disorder, nervous disorders, respiratory illness, digestive disorder, liver disease, kidney or urinary disorder, metabolic disorder, eye disease, ENT disease dermatological or sexual disease or any other medical problem?  
3. Have you at any time required an operation?  
4. Have you at any time suffered an injury as a result of an accident?  
5. Have you at any time suffered from any form of disability?  
6. Have you suffered from any illnesses or are you aware of any health condition?  
7. Are you on medication for any medical disorder?  
For women only  
8a. Are you pregnant?  
8b. Women's diseases: menstrual cycle disorders, breast disease (including lumps in the breast), uterus, ovaries, examinations for detection of a cancerous growth, memmography? Please specify.  

Details about the existing conditions. If you responded "yes" to any of the above questions, please note the question number, followed by details (including the date) of the condition. In addition, please attach a letter from your physician stating the current status of the condition.

Question No. Details Year
C. Personal Declaration
 
I hereby declare that I am not suffering from any illness or accident. I am not handicapped. I am not undergoing any medical treatment of any kind. I do not, nor have I in the past suffered from any chronic medical condition (such as heart disease, high blood pressure, disability, etc. or a congenital disability, or a malignant disease).
I am not aware of any need for medical treatment, hospitalization or surgery.
I am aware that the coverage for worsening of a present illness under the Platinium Care policy is subject to the terms and exclusions of the policy

Renunciation of Medical Confidentiality: I, the undersigned, hereby give my permission to the health service provider 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 any institute, other body and/or individual to provide Harel Insurance Company Ltd. (hereinafter "the requestor") with all the details, without exception, and in the manner required by the Requestor regarding 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, regarding the Harel policy, and I hereby release you from any obligation to safeguard medical confidentiality and renounce this confidentiality.

Toward the Requestor. This Declaration of Renunciation binds me, my estate and my legal delegates and anyone who will come in my stead. This Declaration of Renunciation shall also apply to minors.

D. Details of Health Insurance in Home Country
 
Insurance company:
Policy Number:
I have health insurance in my home country, but do not remember the details.
I have no health insurance in my home country.
E.
 I hereby certify that all the information I have provided on this form is accurate and true.
F.
 I am aware that the validity and scope of this insurance policy are determined by the health declaration that I have completed and signed, as well as by other factors. By signing this document, I am hereby responsible to inform the Harel Insurance Co. immediately of any change in my medical condition that occurs during the period between the date of my signature on the health declaration and the beginning of the insurance policy. Furthermore, without derogating from any legal right held by the Harel Insurance Co. in accordance with the terms of the policy, I am aware that this policy will in no event cover any new medical condition that occurs during the period between the date of my signature on the health declaration and the beginning of the insurance policy.
* Date:
 
* Signature:
 
Contact Center: Yedidim, Division for Overseas Visitors and Students
Beit Hakristal, 12 Hahilazon St., 8th Floor, Ramat Gan 52522,
Tel: 972-3-6386216, Fax: 972-3-6874534,
E.mail: y_health@yedidim.co.il, www.yedidim-health.co.il