International Health Insurance Form

Your personal details - Main Applicant:
Fields marked * are mandatory

Title *

Please Select Mr Mrs Miss Ms Dr Other

First Name *

Surname *

Occupation

Date of Birth*

Nationality on Passport
{dual nationals please state both}

Currency in which you would like your quote

Your Spouse's personal details

First Name

Surname

Date of Birth

Nationality on Passport
{dual nationals please state both}

Dependents' personal details
Only supply this information if you wish to include dependents on your policy

First Name

(Dependent 1)

Surname

Date of Birth

Nationality on Passport
{dual nationals please state both}

First Name

(Dependent 2)

Surname

Date of Birth

Nationality on Passport
{dual nationals please state both}

First Name

(Dependent 3)

Surname

Date of Birth

Nationality on Passport
{dual nationals please state both}

First Name

(Dependent 4)

Surname

Date of Birth

Nationality on Passport
{dual nationals please state both}

If you have more than 4 dependents, please specify in the comments box below.

Your contact details: Main Applicant {Where you are currently resident}

Address *

City/Town

County/State/Province

Postcode/Zipcode *

Country

Email *

Phone *

Additional Information

Country where cover is required *

Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia (local name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Falkland Islands (Malvinas) Faroe Islands Fiji Finland France France, Metropolitan French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Holy Vatican City State Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto rico Qatar Reunion Romania Russian Federation Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Islands Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United Kingdom - Isle of Man United Kingdom - Channel Islands United States United States minor outlying islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Islands Western Sahara Yemen Yugoslavia Zambia Zimbabwe

Who is your current medical insurer?

Expiry Date of Current Insurance
{{if any}}

(dd/mm/yy)

Cover required from

How long do you want cover for? *

(i) Do any of the above have pre-existing medical condition?

Yes No {If yes, please state below}

Pre-Existing Medical Condition(s){if any}

(ii) Are any of the above taking prescribed medication?

Yes No

If yes, please state here

Additional questions, comments or suggestions, (include any other dependents and ongoing pre-existing conditions)