1. Do you require cover for more than 10 employes?

   No

   Yes

2. Contact Name: *

3. Company Name: *

4. Telephone: *

5. Email: *

6. Address: *

7. Post Code: *

8. Current medical Incurance Provider: *

9. Policy renewal Date: *

10. Pay Premiums:

    Annually
    

    Monthly
    

11. Excess level - e.g. £100 per year:

 

 

1st Employee

12. Employees Name:

13. Date of Birth:

14. Spouse/Partners name:

15. Date of Birth:

16. No. of children under 21yrs:

 

 

2nd Employee

17. Employees Name:

18. Date of Birth:

19. Spouse/Partners name:

20. Date of Birth:

21. No. of children under 21yrs:

 

 

3rd Employee

22. Employees Name:

23. Date of Birth:

24. Spouse/Partners name:

25. Date of Birth:

26. No. of children under 21yrs:

 

 

4th Employee

27. Employees Name:

28. Date of Birth:

29. Spouse/Partners name:

30. Date of Birth:

31. No. of children under 21yrs:

 

 

5th Employee

32. Employees Name:

33. Date of Birth:

34. Spouse/Partners name:

35. Date of Birth:

36. No. of children under 21yrs:

 

 

6th Employee

37. Employees Name:

38. Date of Birth:

39. Spouse/Partners name:

40. Date of Birth:

41. No. of children under 21yrs:

 

 

7th Employee

42. Employees Name:

43. Date of Birth:

44. Spouse/Partners name:

45. Date of Birth:

46. No. of children under 21yrs:

 

 

8th Employee

47. Employees Name:

48. Date of Birth:

49. Spouse/Partners name:

50. Date of Birth:

51. No. of children under 21yrs:

 

 

9th Employee

52. Employees Name:

53. Date of Birth:

54. Spouse/Partners name:

55. Date of Birth:

56. No. of children under 21yrs:

 

 

10th Employee

57. Employees Name:

58. Date of Birth:

59. Spouse/Partners name:

60. Date of Birth:

61. No. of children under 21yrs:

*This information is required for an enquiry

This information will be treated in the strictest confidence. Some medical insurance companies will base their premiums on whether or not you have existing medical conditions.