About you... Your Name: Company Name: Nature of business: Your full postal address: Your telephone No. Your email address: Insurance Needs... Do you currently have Medical Insurance in place? Current Insurer:
AIG - HealthNow
AXA PPP healthcare
B.C.W.A
BUPA
CIGNA
Clinicare Ltd (now Groupama)
C S Healthcare
Exeter Friendly Society
First Assist
Freedom HealthNet
General & Medical
Groupama Healthcare
Health-on-line
H-S-A (medical insurance)
Legal & General Healthcare
Norwich Union Healthcare
Permanent Health Co.
PPP healthcare
Pru Health
SAGA
SecureHealth Ltd
Universal Provident
WPA - Western Provident Ass.
> Not on this list
Current Underwriting Used:
Moratorium
Full Medical Declaration
Mixed Underwriting
Medical History Disregarded
Unknown at this time
Important benefits... Please select from the list below which benefits are most important to you and your family: Cover to cover treatment of Cancer Cover for Hospitalisation (in-patient / day-case) Cover for Out-patient Consultations and tests Complimentary Medicines and Therapies (Physio) Cover for Psychiatric Conditions Cover for Optical and Dental expenses Employee Assistance Program Required? Excess Options... By agreeing to pay the first part of a claim, your premiums will be reduced. Excess Preference:
No Excess
up to £100
up to £250
up to £500
up to £750
up to £1,000
up to £1,500
up to £2,000
up to £2,500
over £2,500
Excess Type:
Employee and Dependant
Dependant Only
Shared Risk (% of claim)
Preferred Start Date: Membership... Membership Details: Once received - we will contact you for these details... (Small Group) Membership Details: Allowed extensions: .doc,.xls,.pdf
Comments / Concerns: 
