Please enter the information about your organization:
Contact Person:
Name:
Position:
Phone(s):
e-mail:
Please confirm e-mail:
Please select components of the benefit package. The figures indicate in what extent the service is covered by the Health Plan.
For example, if you want the Specialist Services to be covered completely, type 100 in the corresponding cell (in the column for Employees and/or for Family Members). If you want to get partial coverage, you can type 40. That is, you will pay 60% of the cost, and the health plan will cover the rest 40%.
If you don't want to include a service, leave the cell blank or type 0.
For Employees
For Family Members
General Practitioners Services
%
Specialists Services
Diagnostic Services
Emergency Services (Ambulance)`
Urgent Dental Care
Hospital Care
Pharmaceuticals