CSI Opal - Chabad Shluchim International
Date of Birth:
Number of insured including policy holder:
Individuals and couples (1/2 persons): USD 2,662.89 per year, per personFamilies (3 or more persons): USD 7,410.12 flat per year, covering all family members (regardless the number of children)
Number of members in your policy:
Death and disability after accident:
WCA Membership - WCA membership fees are included in the premium.
Declaration I declare that the answers given, whether in my handwriting or not, are true and complete to the best of my knowledge and belief and will form the basis of the certificate of insurance for my application for the Plans.
I understand that failure to disclose any material fact may invalidate the certificate of insurance. Note: A material fact is one which may influence the assessment or acceptance of your application for the Opal Plans. If you are in any doubt as to the relevance of any information, please give details. Failure to disclose a material fact may invalidate your certificate of insurance resulting in the loss of your benefits.
I agree to inform my Opal representative in writing of any change in my circumstances between the date of this application and issue of the certificate of insurance. I also agree to inform the company of any change of name, change of address etc. that may occur during the life of the Plan.
I consent to the company seeking independent verification (if considered necessary) of any of the information given in this application. Any disputes under the Plans shall be ruled only by courts located in Luxembourg.
Data Protection - I understand that the information that I supply will be held and used for the purposes of administration of the Opal Plans by any of your group companies, by re-insurers, by third parties who provide relevant services to me.
Any information given by the participant or their advisor will be used solely by the insurance companies, in accordance with the Data Protection Act.
By signing this proposal, I declare to be the beneficial owner of the funds used to pay the insurance premium.
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August 5, 2021
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Document Name: CSI Opal - Chabad Shluchim International
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