תשובות לשאלון – תביעה לקביעת נכות מהעבודה
טופס ההגשה המלא – תביעה לקביעת נכות מהעבודה
- Personal Info Last Name 1 1: ברונובסקי
- Personal Info First Name 1 2: דימיטרי
- Personal Info Id 1 3: 304370653
- Personal Info Address City 3 5: תל אביב
- Personal Info Address Street 3 1: דרך שלמה
- Personal Info Address House Number 3 2: 46
- Personal Info Address Entrance 3 3: C
- Personal Info Address Apartment 3 4: 11
- Personal Info Address Index 3 6: 6608936
- Personal Info Army Personal Number 2 3: 2221111
- Personal Info Gender 2 1: זכר
- Personal Info Do For Living 2 2: שכיר
- Injury Date 6: 30/11/2025
- Injury Injury Details 7: אלה הם הפרטים על הפגיעה
- Workplace Info Checkbox: true
- Workplace Info Name 1 1: מקום העבודה שלי
- Workplace Info Phone 1 2: 0500500500
- Workplace Info Phone 2 1: שם רחוב מקום עבודה
- Workplace Info House 2 2: 44
- Workplace Info Entrance 2 3: 3
- Workplace Info Apartment 2 4: 88
- Workplace Info City 2 5: תל אביב
- Workplace Info Index 2 6: 000000
- Workplace Info Profession 3: שם מקצוע
- Medical Info Hospitalisation No 9: כן
- Medical Info Hospitalisation Name 9 3: איכילוב
- Medical Info Hospitalisation Date Range 9 4: 15/12/2025
- Medical Info Tests No 10: לא
- Medical Info Insurance Company Name 12: כללית
- Medical Info Doctor Name 13 1: ששש
- Medical Info Doctor Specialty 13 2: שש
- Medical Info Doctor Address 13 3: שש
- Limitations Type 1 1: שש
- Limitations Docnames 1 2: שש
- Limitations Past Suffer No 4: לא
- Return To Work Yes Same 5: כן – חזרתי לאותה העבודה
- Hebrew 11: אגיע לוועדה עם מלווה דובר עברית
- Payment Details Ministry Defence Payment No 14: לא
- Payment Details Ministry Defence Lawsuite No 15: לא
- Form Filling Assist 16: true
- Form Filling Assist 17: true
- Bank Holder Name 1 1: שש
- Bank Holder Name 1 2: שש
- Bank Holder Name 1 3: שש
- Bank Name 2 1: שש
- Bank Branch Name Or Address 2 2: שש
- Bank Branch Number 2 3: ש
- Bank Account Number 2 4: ששש
- Bank Account Kibutz 3: לחשבוני הפרטי
- Bank Holder Partner Id Number 4 1: שש
- Bank Holder Partner Name 4 2: שש
- Current Date: 22/12/2025
- Bank Holder Sig Pension Holder Name 5 2: https://bshvili.co.il/wp-content/uploads/dscf7_signatures/bank_holder_sig_pension_holder_name_5_2-1772959250.png
- Bank Holder Sig Pension Holder Name 5 2 Attachment: /var/www/html/wp-content/uploads/wpcf7_uploads/3372477734/bank_holder_sig_pension_holder_name_5_2-1772959250.png
- Bank Holder Sig Partner Signature 5 3: https://bshvili.co.il/wp-content/uploads/dscf7_signatures/bank_holder_sig_partner_signature_5_3-1772959250.png
- Bank Holder Sig Partner Signature 5 3 Attachment: /var/www/html/wp-content/uploads/wpcf7_uploads/4100107418/bank_holder_sig_partner_signature_5_3-1772959250.png
- Decleration Concent Sig Signature 8 2: https://bshvili.co.il/wp-content/uploads/dscf7_signatures/decleration_concent_sig_signature_8_2-1772959250.png
- Decleration Concent Sig Signature 8 2 Attachment: /var/www/html/wp-content/uploads/wpcf7_uploads/3884887007/decleration_concent_sig_signature_8_2-1772959250.png
- Medical Info Share Personal Details Healthcare Provider Clalit 3: מאוחדת
- Medical Info Share Personal Details Injury Sig 5: https://bshvili.co.il/wp-content/uploads/dscf7_signatures/medical_info_share_personal_details_injury_sig_5-1772959250.png
- Medical Info Share Personal Details Injury Sig 5 Attachment: /var/www/html/wp-content/uploads/wpcf7_uploads/1269024338/medical_info_share_personal_details_injury_sig_5-1772959250.png
- Service Id: 911
