Corporate Clients

Please complete all of the following fields.
**Denotes compulsory field

Name **

Contact Number **

Email **

Preferred contact method

Please select Phone Email

Are you a new or existing client?

Please select New Existing

If new, please advise how you got our name

Please select Websearch Recommendation Advertising Other

If existing, please enter your Client Reference if known

Do you currently have Private Medical insurance?

Please select Yes No

If yes, what is the renewal date?

D: M: Y:

What is the current annual premium that you pay?

How many employees require individual only cover?

How many employees require cover for themself and their spouse?

How many employees require cover for themself and a child?

How many employees require cover for themself, spouse and children?

Personal Details (Main policyholder)

Name

Date of Birth

D: M: Y:

Gender

Please select Male Female

Details of spouse (if applicable)

Name

Date of Birth

D: M: Y:

Gender

Please select Male Female

Details of eldest child requiring cover (if applicable)

Name

Date of Birth

D: M: Y:

Gender

Please select Male Female

Have you had any claims under this type of policy in the past 3 years?

Please select Yes No

If yes, please specify the number

Please select 1 2 3 4 5 6 7 8 9 10

Please provide any further details relating to your application (e.g. please detail any cancer related problems / advise whether anyone on this submission is currently receiving medical treatment / advise if coverage outside UK is required)