1. Do you require cover for more than one person?

   No

   Yes

2. Mr Mrs Ms Miss

3. Name: *

4. Date of Birth: *

5. Telephone: *

6. Email: *

7. Address: *

8. Post Code: *

9. Occupation: *

10. Do you have existing Medical insurance cover?

    Yes
    

    No
    

11. If Yes – What is renewal date?

12. Are you self employed?

    Yes
    

    No
    

13. Are you a smoker?

    Yes
    

    No
    

14. Do you or your family have a history of cancer, heart attacks or strokes?

    Yes
    

    No
    

15. Day case + in-patient treatment (compulsory cover):

    Yes
    

16. Out-patient cover?

    Yes
    

    No
    

17. Out-patient cover limit per year:

    £500
    

    £1000
    

    No Limit
    

18. Cancer cover?

    Yes
    

    No
    

19. Therapies - eg. physiotherapy?

    Yes
    

    No
    

20. Psychiatric treatment?

    Yes
    

    No
    

21. Six week wait - reduces costs?

    Yes
    

    No
    

22. Minor other benefits?

    Yes
    

    No
    

23. How much excess do you wish to pay?

    £0
    

    £100
    

    £200
    

    £250
    

    £300
    

    £500
    

    £1000
    

24. What is your maximum monthly budget?

25. Does anyone to be covered have an existing medical condition where they have seen the doctor or specialist within the last 5 years or are taking long-term medication?

    Yes
    

    No
    

26. If yes, please give the name of the person and brief details of the medical condition and any medication:

*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.