1. The information included in this document is necessary for consideration of your application and for determination

and implementation of the terms of your policy. The Company and other companies of the Harel Group (Harel Insurance Investment and Financial Services and its subsidiaries) and/or anyone on their behalf will use it, including processing, storing and use thereof, for any matter pertaining to the policies and for other legitimate purpose, including providing the information to their parties acting on its behalf and on behalf of the Harel Group.

1. I hereby declare that all the answers are correct and complete and are given out of my own free will.

2. The answered provided in the Health Declaration and any other information that is submitted to the Company now or in the future, as well as the Company’s customary prevailing terms and conditions shall be essential terms and conditions of the insurance contract with the Company and constitute an inseparable part thereof.

3. 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 the Insurance Applicant.

4. This Health Declaration and Insurance Applicant’s Statement shall also apply to any children for whom policies are issued in which you are named their guardian. Are you authorized to sign these documents on their behalf? Yes No

1. For your information: “Pre-existing medical condition” refers to an insurance event substantially caused by

the normal course of a pre-existing medical condition that occurs to the Insured during the period of the restriction. The restriction due to a pre-existing medical condition is determined by the age of the Insured at the beginning of the insurance period, as follows:

1. Under 65 years of age at the beginning of the insurance period – the restriction shall apply for a period not

exceeding one year from the beginning of the insurance period.

1. 65 years of age or older at the beginning of the insurance period – the restriction shall apply for a period not exceeding half a year from the beginning of the insurance period.

1. This health insurance is subject to a qualifying period of 48 hours.

2. I am aware that the insurance contract shall come into force only after the Company issues a written confirmation of acceptance of the Insurance Applicant. In any case, the insurance period shall begin upon confirmation by the Insurer, as noted.

3. Waiver of medical confidentiality: I, the undersigned, hereby give permission to the HMO and/or its medical

institutions and/or the Israel Defense Forces, and to all physicians and/or psychiatrists, medical institutions and other hospitals, to the National Insurance Institute and/or to the Ministry of Defense and/or to any insurance company and/or to any other institution or entity, to the extent necessary in order to clarify the rights and obligations under the policy and/or for the procedure of examining my application for insurance, including any information available to the Company, to deliver to Harel Insurance Company Ltd., hereinafter, the “Requesting Party,” all information without exception and in the form required by the Requesting Party/Parties, concerning my health condition, any illness I had in the past and/or which I have now and/or will have in the future, and I hereby release you from the obligation of maintaining medical confidentiality and waive this confidentiality  in favor of the Requesting Party. This waiver obligates me, my estate and my legal representatives and anyone who would replace me. This waiver shall also apply to my minor children.