Private medical insurance : Enquiry form

This form is for requests for further information about private medical insurance for individuals. We will forward your request to suitable private health insurance brokers and providers. You can also request someone to call you to provide a quotation or discuss your requirements.

If you are seeking private medical insurance for business and the self-employed, use this enquiry form.

» Required Fields

» Title (Mr/Ms/Mrs/Miss)

» First name)

» Surname

» Gender

Female
Male

» Date of birth (dd/mm/yyyy)

» Occupation

» House number and street

» City/Town

County

» Postcode

» Day time telephone no.

» Email address

Name of company you are currently insured with

» Are you looking for comprehensive or standard cover?

Standard (no outpatient cover)
Comprehensive

» Amount of excess required (£)

» When would you like your cover to start?(dd/mm/yyyy)

» I would like to receive a quote for

Myself
Myself and spouse/civil partner/partner

Number of children aged 18+

Number of children aged 0 - 17

» Paying your premium:

Monthly
Quarterly
Annually

» Your height: Metres

» Your weight: Kgs

» Have you smoked tobacco products in the last 3 years?

Yes
No

» Have you or any person included in this enquiry had an operation or hospital treatment, or visited a specialist/consultant in the last 3 years?

Yes
No

» How much time do you spend a week participating in exercise or sport?

» Please provide a quotation

By post
By email
By telephone

(From time to time, we may email you information about healthcare services that may interest you. Your contact details are NOT disclosed to third parties, and will not be sold to spam emailers. We are ANTI SPAM. If you do not wish to receive such email communication from us, please indicate below.

Email Preference

I am happy to receive occasional emails
I do not wish to receive occasional emails