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 select Business Personal Total Number of Scheme Members Scheme Member Name 1 Scheme Member DOB 1 MM slash DD slash YYYY Scheme Member Name 2 Scheme Member DOB 2 MM slash DD slash YYYY Scheme Member Name 3 Scheme Member DOB 3 MM slash DD slash YYYY Scheme Member Name 4 Scheme Member DOB 4 MM slash DD slash YYYY Scheme Member Name 5 Scheme Member DOB 5 MM slash DD slash YYYY Scheme Member Name 6 Scheme Member DOB 6 MM slash DD slash YYYY Scheme Member Name 7 Scheme Member DOB 7 MM slash DD slash YYYY Scheme Member Name 8 Scheme Member DOB 8 MM slash DD slash YYYY Scheme Member Name 9 Scheme Member DOB 9 MM slash DD slash YYYY Scheme Member Name 10 Scheme Member DOB 10 MM slash DD slash YYYY Scheme Member Name 11 Scheme Member DOB 11 MM slash DD slash YYYY Scheme Member Name 12 Scheme Member DOB 12 MM slash DD slash YYYY Scheme Member Name 13 Scheme Member DOB 13 MM slash DD slash YYYY Scheme Member Name 14 Scheme Member DOB 14 MM slash DD slash YYYY Scheme Member Name 15 Scheme Member DOB 15 MM slash DD slash YYYY Scheme Member Name 16 Scheme Member DOB 16 MM slash DD slash YYYY Scheme Member Name 17 Scheme Member DOB 17 MM slash DD slash YYYY Scheme Member Name 18 Scheme Member DOB 18 MM slash DD slash YYYY Scheme Member Name 19 Scheme Member DOB 19 MM slash DD slash YYYY Scheme Member Name 20 Scheme 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 select Local National National inc. London Don’t know N/A Underwriting Type RequiredPlease select Moratorium (previous health conditions excluded but re-assessed every 2 years) Full medical Underwriting (exclusions remain for full policy life) Previous conditions disregarded Don’t know N/A Excess Amount (if known)Please select £0 £100 £250 £500 £1,000 £2,500 £5,000 Don’t know Outpatient CoverPlease select £500 £750 £1,000 £1,250 £1,500 Full Outpatient Limit Is Travel Cover also required?Please select No Europe Worldwide ex Canada, US, Carribean Worldwide Excess Type (if known)Please select Per Person Per Plan Year Per Person Per Claim Don’t know Cover RequirementsPlease complete this if known Refused insurance, insurance proposal declined, had insurance cancelled, any renewal refused or any special conditions imposed?Please select Yes No Please provide further information Defaulted on any Instalment Agreement?Please select Yes No Please provide further information Convicted of a criminal Offence or received a police caution in the last 5 years?Please select Yes No Please provide further information Subject to a County Court Judgement (CCJ or Scottish equivalent), satisfied or otherwise?Please select Yes No Please provide further information Been declared Bankrupt?Please select Yes No Please provide further information Been a Director of a liquidated company or disqualified as a director, Or part of company subject to winding up procedures?Please select Yes No Please provide further information CAPTCHA