Quotation - FREE request for Group Health Insurance

Please complete the form below for a Free, No Obligation Quotation which we will supply shortly.

US Companies/Employees - Please note that we are unable to offer coverage to US companies/employees who are permanently based only in the USA.

If you would like someone to contact you by telephone to discuss your needs in more detail, please let us know in the "Questions" box at the end of this form and we will call you at a convenient time to give you information about our plans and answer any questions that you may have.

*Required Fields

CONTACT DETAILS

*GROUP / COMPANY NAME

*CONTACT NAME

ADDRESS

TOWN / CITY

STATE / PROVINCE / COUNTY

POST/ZIP CODE

COUNTRY OF RESIDENCE

If you require cover in more than one country, please advise the amount of time you are likely to spend in each country per year

*E-MAIL (REQUIRED)

*CONFIRM E-MAIL

*DAYTIME TELEPHONE NUMBER

HOME/MOBILE TELEPHONE NUMBER

CONTACT FAX NUMBER

YOUR NEW POLICY

DO YOU REQUIRE A QUOTATION FOR
COMPREHENSIVE OR STANDARD COVER?

Comprehensive
Standard (no outpatient cover)

DO YOU WISH TO PAY PREMIUMS

Monthly
Quarterly
Annually

CURRENCY

PLEASE DETAIL: NAME, DATE OF BIRTH AND NATIONALITY OF EACH PERSON REQUIRING COVER.

CURRENT INSURER

DO YOU PRESENTLY HAVE
MEDICAL INSURANCE COVER?

Yes
No

WHEN DO YOU REQUIRE COVER TO START?

Day:

Month:

Year:

IF YOU PRESENTLY HAVE
MEDICAL INSURANCE COVER?

Who is your present medical insurer?

How much is your present premium?

OTHER COMMENTS & QUESTIONS

USE THIS BOX FOR ANY QUESTIONS THAT YOU MAY HAVE FOR US

REQUEST OUR FREE NEWSLETTER?

Yes - please send

HOW DID YOU DISCOVER OUR SITE?

Search Engine:

Other, Please Specify:

PLEASE SEND ME A FREE NO OBLIGATION QUOTATION BASED ON THE ABOVE

You may be assured that all personal details entered on this form will remain confidential to Medibroker Online and will not be disclosed to third parties nor will any detail or address be used for marketing purposes. Please ensure, however, that you fill out every box.

Contact Us

International Telephone

+44 (0)191 297 2411

Freephone

0800 980 1082 (UK)

clientservices@
medibroker.com

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