APPLICATION FORM

Dear Applicant,

We are happy to assist you with any questions you may have while completing this form.

The insurance quote is valid for 45 days from the date it is issued by the insurer.

This form must be completed in its entirety.

If you currently have insurance coverage, we recommend that you do not cancel it until you receive

official confirmation of your acceptance into the new insurance plan.

1 | General Details

The requested health insurance is intended to provide coverage for my potential liability for the covered medical expenses of a

newborn to be born pursuant to a surrogacy agreement in the Country of Destination/State/Province:

2 | Personal Details and Surrogate Information

Primary Applicant Details

Secondary Applicant Details (Optional)

Surrogate Information

3 | Permanent Address in Country of Origin and Contact Details

4 | Contact Person (Attorney-in-fact) for Receiving Documents or in Emergency Situations

5 | Applicants’ Declaration

I, the undersigned, hereby request on behalf of myself and my family members to be insured according to this declaration.

I declare that all my answers, as detailed in this application and other declarations of myself and my family members (as

applicable), are complete and truthful.

I am aware that my answers will serve as the basis for the requested insurance contract and will form an integral part thereof.

I understand that incomplete and/or incorrect answers and non-disclosure of material facts regarding the application and

health declaration may result in cancellation of the policy, denial of claims, and other actions as provided by law.

Regulatory Authority: I am aware that the policy is regulated by the State of Israel – Ministry of Finance – Capital Market,

Insurance and Savings Authority.

Insurer: DavidShield Insurance Company Ltd.

Notices: I am aware and agree that notices and correspondence may be sent, as needed, to my postal address and/or email

and/or on the personal area on the company’s website. I also acknowledge and agree that the policy, registered letters, and

legal documents will be sent via email only using a link to the personal area, and their delivery shall be considered lawful.

Jurisdiction and Applicable Law: I understand that this is an Israeli policy subject to Israeli law and jurisdiction only, and even

if completed via phone/mail/other means, it was executed in Israel. Legal venue is a competent court in Israel or arbitration

institution as detailed in the Policy.

Policy Language: I acknowledge and agree that for clarification of any issue related to this insurance, the binding version is

the policy itself.

Service Providers: I understand and agree that my and my insured family members' details may be transferred to medical

providers on behalf of the insurer and/or DavidShield for the purpose of providing services in accordance with the policy and

will be stored in the insurer’s information systems for this purpose.

By signing this form, I declare and confirm acceptance of the privacy policy of DavidShield Insurance Agency Ltd. and/or

DavidShield Insurance Company Ltd. as published on the company website. 

6 | " Doctor’s Room" Service - Declaration

I declare that I understand and agree that: The Doctor’s Room is operated by physicians who provide assistance and

consultation on medical issues based on their best professional knowledge and judgment.

Consultations are given based solely on medical considerations and in accordance with medical ethics. It is my responsibility

to verify whether my health insurance policy covers the recommendations provided.

The consultation is inherently limited as it is not accompanied by a physical examination and is based on my subjective

description of the medical issue. Accordingly, I understand and agree that this service does not constitute medical

instructions or a substitute for a physician's examination

Primary Applicant:

Secondary Applicant:

7 | Medical Confidentiality Waiver

You are about to sign a "Medical Confidentiality Waiver", meaning you waive your right and that of other insureds under this

policy to the confidentiality of medical information. We will use the following waiver solely for matters related to determining

liabilities and entitlements under this policy.

Note: Each applicant over age 18 must sign this waiver.

By signing below, you authorize public (HMOs) and/or private health services, their employees, institutions, or branches, your

treating physician(s) and/or those of your insured family members, and any other medical institution treating you or them

to provide DavidShield Insurance Company Ltd. and/or DavidShield Insurance Agency Ltd. or their representatives with

any and all information required concerning health status, existing or past illnesses, and any relevant findings or diagnoses

necessary to determine rights and obligations under the policy.

By signing, you release the entities listed above from their obligation of medical confidentiality, and you will have no claims of

any kind against them for disclosing such information. This waiver binds the undersigned, their estates, legal representatives,

and successors.

By signing below, you also declare and confirm that DavidShield will provide you access to a self-service website and mobile

app where you can view the policy and all insured members, including details of the secondary applicant and children, and

perform actions such as updating personal information and submitting claims.

I/We freely give consent to the DavidShield Insurance Company Ltd. and/or DavidShield Insurance Agency Ltd. to share

confidential information with each other for the purpose of administering and servicing. I/We understand that this may

include sensitive personal or health information concerning the newborn to be born through the surrogacy arrangement.

I/We understand that providing this consent is voluntary and that refusal may prevent the DavidShield Insurance Company

Ltd. and/or DavidShield Insurance Agency Ltd. from providing certain services related to the policy.

Primary Applicant Declaration:

Secondary Applicant Declaration:

Applicants’ Signature(s)

8 | Consent to Share Information:

By signing this clause, I/We freely give consent to the DavidShield Insurance Company Ltd. and/or DavidShield Insurance

Agency Ltd. to share confidential information with my assigned insurance agent/broker for the purpose of administering

and servicing. I/We understand that this may include sensitive personal or health information concerning the newborn to be

born through the surrogacy arrangement.

Applicants’ Signature(s)

9 | Data Subject Rights :

I/we know that one may withdraw the consents granted in this Application Form at any time by providing notice to

Surrogacy@passportcard.com . I/We understand that under applicable law, I/we have the right to request access to, and a copy

of, the personal data held about me/us, to request correction, deletion, or restriction of processing, and to lodge a complaint

with a supervisory authority.