Name (or if in a Company Name please state):*Lookup Your Post Code: Address Line 1*Address Line 2*Address Line 3*Town*Postcode*Occupation/Industry:*Private Medical Contact (i.e the best person to contact regarding this insurance)*Email address:* Mobile Number*Current PMI Insurer*Type of schemePlease selectBusinessPersonalTotal Number of Scheme MembersScheme Member Name 1Scheme Member DOB 1 MM slash DD slash YYYY Scheme Member Name 2Scheme Member DOB 2 MM slash DD slash YYYY Scheme Member Name 3Scheme Member DOB 3 MM slash DD slash YYYY Scheme Member Name 4Scheme Member DOB 4 MM slash DD slash YYYY Scheme Member Name 5Scheme Member DOB 5 MM slash DD slash YYYY Scheme Member Name 6Scheme Member DOB 6 MM slash DD slash YYYY Scheme Member Name 7Scheme Member DOB 7 MM slash DD slash YYYY Scheme Member Name 8Scheme Member DOB 8 MM slash DD slash YYYY Scheme Member Name 9Scheme Member DOB 9 MM slash DD slash YYYY Scheme Member Name 10Scheme Member DOB 10 MM slash DD slash YYYY Scheme Member Name 11Scheme Member DOB 11 MM slash DD slash YYYY Scheme Member Name 12Scheme Member DOB 12 MM slash DD slash YYYY Scheme Member Name 13Scheme Member DOB 13 MM slash DD slash YYYY Scheme Member Name 14Scheme Member DOB 14 MM slash DD slash YYYY Scheme Member Name 15Scheme Member DOB 15 MM slash DD slash YYYY Scheme Member Name 16Scheme Member DOB 16 MM slash DD slash YYYY Scheme Member Name 17Scheme Member DOB 17 MM slash DD slash YYYY Scheme Member Name 18Scheme Member DOB 18 MM slash DD slash YYYY Scheme Member Name 19Scheme Member DOB 19 MM slash DD slash YYYY Scheme Member Name 20Scheme Member DOB 20 MM slash DD slash YYYY Current Renewal Date MM slash DD slash YYYY General InformationHas any person to be insured, plan member, or the proposer, ever been:Hospital List RequiredPlease selectLocalNationalNational inc. LondonDon’t knowN/AUnderwriting Type RequiredPlease selectMoratorium (previous health conditions excluded but re-assessed every 2 years)Full medical Underwriting (exclusions remain for full policy life)Previous conditions disregardedDon’t knowN/AExcess Amount (if known)Please select£0£100£250£500£1,000£2,500£5,000Don’t knowOutpatient CoverPlease select£500£750£1,000£1,250£1,500Full Outpatient LimitIs Travel Cover also required?Please selectNoEuropeWorldwide ex Canada, US, CarribeanWorldwideExcess Type (if known)Please selectPer Person Per Plan YearPer Person Per ClaimDon’t knowCover RequirementsPlease complete this if knownRefused insurance, insurance proposal declined, had insurance cancelled, any renewal refused or any special conditions imposed?Please selectYesNoPlease provide further informationDefaulted on any Instalment Agreement?Please selectYesNoPlease provide further informationConvicted of a criminal Offence or received a police caution in the last 5 years?Please selectYesNoPlease provide further informationSubject to a County Court Judgement (CCJ or Scottish equivalent), satisfied or otherwise?Please selectYesNoPlease provide further informationBeen declared Bankrupt?Please selectYesNoPlease provide further informationBeen a Director of a liquidated company or disqualified as a director, Or part of company subject to winding up procedures?Please selectYesNoPlease provide further information CAPTCHA