1 - About You

Title * :

Mr Mrs Ms Miss Master Other

First name * :

Last name * :

Date of birth DD/MM/YYYY * :

/ /

Nationality, as on passport * :

Country/countries where cover required * :

Occupation :

Do you wish to include spouse/dependant * :

Yes

No

3 - Medical History

If you have any pre-existing medical conditions or are currently receiving medical treatment, please provide details:

4 - Your Contact Details

E-mail address * :

Confirm email address * :

Alternative E-Mail Address :

Daytime Telephone Number * :

Address 1 :

Address 2 :

Town/ City :

State / Province / County :

Post/ Zip code :

Country * :

5 - Further Information & Submit

Please use this box to provide any further information or ask any questions that you may have for us:

On an annual basis we carry out a customer satisfaction survey (carried out in confidence by a third party market research company employed by APRIL GROUP) in order to assess our service levels and standards.

Would you like to participate ? * :

Yes

No

We offer an APRIL Medibroker newsletter by E-mail.

Would you like to subscribe? * :

Yes

No

Please provide the answer to this question

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Use of your information will solely by used by APRIL Medibroker and any personal information will remain confidential within normal procedures in advising on and completing applications for private medical insurance and associated plans. Your information will not be disclosed to any third parties outside of APRIL GROUP or used for unsolicited marketing.


	Standardcare				Key Benefits:

	Standardcare offers cover for in-patient hospital treatment with some provision for follow-up out-patient treatment. It covers the more expensive element of any course of treatment which is the in-patient hospital stay, together with the reassurance that if it is necessary to carry out an emergency medical evacuation, cover for this is automatically included in the plan				Overall policy limit of £1,000,000 or $1,700,000 or €1,500,000 Full refund on in-patient hospital and day-patient treatment including treatment for cancer and chronic conditions Organ transplants covered up to £100,000 or $170,000 or €150,000 Emergency medical evacuation
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	Executivecare				Key Benefits:

	The Executivecare plan gives the reassurance that the cost of out-patient treatment will be covered as well as the major inpatient hospital expenses. As with Standardcare, cover for emergency medical evacuation is included automatically. For consultations, GP visits and diagnostic services the cover is a full refund with additional benefits for prescription drugs, vaccinations occupational therapy and complementary therapies.				Overall policy limit of £1,500,000 or $2,550,000 or €2,250,000 Full refund for in-patient hospital and day-patient treatment, including cancer and chronic conditions Full refund for out-patient treatment including cover for private GP visits and treatment and monitoring of chronic conditions Cover for prescription drugs and vaccinations Benefit for complementary therapies Emergency medical evacuation
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	Specialcare				Key Benefits:

	Specialcare is the Expacare plan with the most wide-ranging benefits and offers cover that compares favourably with other leading products in the market. All the key elements of cover are included: in-patient hospital expenses, out-patient benefits, prescription drugs and vaccinations and routine medical examinations. In addition Specialcare includes cover for maternity care with treatment for birth defects and congenital illness, routine dental treatment, treatment for alcohol and drug addiction and lump sum payment on diagnosis of AIDS.				Overall policy limit of £5,000,000 or $8,500,000 or €7,500,000 Full refund for in-patient hospital and day-patient treatment, including cancer and treatment and monitoring of chronic conditions Full refund for out-patient treatment including cover for GP visits and treatment and monitoring of chronic conditions Cover for prescription drugs and vaccinations Cover for routine maternity care and maternity cover with complications Benefit for routine dental treatment Wellness benefit for routine medical investigations Lump sum payment on diagnosis of aids Payment for treatment of alcohol and drug addiction Emergency medical evacuation
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Expacare Global Healthcare and Assistance

General Information:

Standardcare

Key Benefits:

Executivecare

Key Benefits:

Specialcare

Key Benefits:

1 - About You

2 - Expacare Global Healthcare Plan & Cover Required

3 - Medical History

4 - Your Contact Details

5 - Further Information & Submit