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International Health Insurance Quote Request:

Please complete the details below to the best of your abilities

About you...
Your Name:
Postal Address:
Telephone:
Email Address:
Cover Required:	Single Couple Family Lone Parent
Nationality:	Select CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia-HerzegovinaBotswanaBrazilBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas Island (Australia)Cocos Island (Australia)ColombiaComorosCongo (Brazzaville),Republic of theCongo, Democratic Republic of theCook Islands (New Zealand)Costa RicaCote d'Ivoire (Ivory Coast)CroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Indonesia)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgia, Republic ofGermanyGhanaGibraltarGreat Britain and Northern IrelandGreeceGreenlandGrenadaGuadeloupeGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotte (France)MexicoMoldovaMonaco (France)MongoliaMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNorth Korea (Korea, Democratic People's Republic of)NorwayOmanPakistanPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts (St. Christopher and Nevis)Saint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia-MontenegroSeychellesSierra LeoneSingaporeSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia (Falkland Islands)South Korea (Korea, Republic of)SpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTogoTokelau (Union) Group (Western Samoa)TongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SamoaYemenZambiaZimbabwe
Residency:	Select CountryAfghanistanAlbaniaAlgeriaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia-HerzegovinaBotswanaBrazilBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurmaBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas Island (Australia)Cocos Island (Australia)ColombiaComorosCongo (Brazzaville),Republic of theCongo, Democratic Republic of theCook Islands (New Zealand)Costa RicaCote d'Ivoire (Ivory Coast)CroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Indonesia)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgia, Republic ofGermanyGhanaGibraltarGreat Britain and Northern IrelandGreeceGreenlandGrenadaGuadeloupeGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotte (France)MexicoMoldovaMonaco (France)MongoliaMontserratMoroccoMozambiqueNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNorth Korea (Korea, Democratic People's Republic of)NorwayOmanPakistanPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts (St. Christopher and Nevis)Saint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia-MontenegroSeychellesSierra LeoneSingaporeSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia (Falkland Islands)South Korea (Korea, Republic of)SpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzaniaThailandTogoTokelau (Union) Group (Western Samoa)TongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and Futuna IslandsWestern SamoaYemenZambiaZimbabwe
Occupation / Purpose:

Those to be covered...
Adult 1: Name:		Date of birth:
Adult 2: Name:		Date of birth:
Child 1: Name:		Date of birth:
Child 2: Name:		Date of birth:
Child 3: Name:		Date of birth:
Child 4: Name:		Date of birth:

Insurance needs...
Do you currently have medical insurance in place ?      Yes No
Current Insurer:

Benefits required...
Yes No	Major Medical Only (hospitalisation & emergency cover)
Yes No	Standard Medical Insurance (limited out-patient cover)
Yes No	Comprehensive Medical (full cover for most benefits)
Yes No	Maternity Cover (cost of routine childbirth)
Yes No	Personal Accident Cover (financial protection)
Yes No	Life / Income (financial protection)
Yes No	Dental cover (routine / emergency)
Yes No	Optical cover
Yes No	Travel cover

Policy preferences...
Excess / Deductible:	Nil - no excess up to £100 / €150 up to £500 / €750 up to £1,000 / €1,500 over £1,000 / €1,500
Preferred start date:
Premium Frequency:	Monthly Quarterly Annually
Preferred currency:	£ GB Pounds € Euro $ US Dollar
Comments / Notes:
= Required

 

 

 

 

 

 

 

 

 

 

 

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Essential Health is an independent health insurance specialist broker based in the UK.
We deal with all aspects of Private Health Insurance including Private Medical Insurance, Income Protection and other forms of Financial Protection as well as Expat Health Insurance. So if you are looking for Affordable Health Insurance for your company or Family Health Cover and would value some assistance, please contact us.
Equally, if you are looking for Affordable Long-term Medical Insurance or Income Replacement to protect your longterm financial well being we are confident that we can help. Our Friendly staff are waiting to see how we can help.

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