Get a Quote - Individuals & Families

Personal Details

Title

MrMrsMissMsDr

Country of Residence

First Name

Country in which you require medical coverage:

Surname

If USA, which state?

Date of Birth

(dd/mm/yyyy)

Daytime telephone number:

Occupation

Email address:

Nationality

Your preferred method of contact:

 email Phone

Cover Details

Area of Cover:

EuropeWorldwide (Excl. US & Canada)Worldwide (Incl. US & Canada

Policy Type:

 Individual Couple Family Parent and Child(ren)

All Other Persons to be insured: Names and dates of birth

Date you require cover to start:

(dd/mm/yyyy)

Policy Features:

 Dental Maternity Outpatient Hospital & Cash Benefit Travel Insurance

 Pounds Sterling Euros US Dolllar

Please specify your excess/deductible requirements:

 Higher (lower premiums) Standard Lower (higher premiums)

What is your budgeted annual premium?

GBP£Euros€USD$

Do you already have health insurance?

 Yes No

If Yes, when is your current policy due to renew?

dd/mm/yyyy

Who is your current health insurance provider?

--AetnaAllianzAXABupaCignaExeter FriendlyExpacareExpatriate HealthcareGoodhealthHTH WorldwideIMGInterglobalMediCare InternationalSevencornersWilliam RussellOther

Please specify any aspects of cover you are looking for:

Additional Information

Would you like information on any other type of insurance:

 Overseas House Contents & Possessions Income Protection Ins UK Let Property Ins

Where did you hear about JBI?

--Conference ExhibitionExisting ClientInternet SearchPrevious ClientRecommendedOther

If other, please state:

Additional Information:

Please type letters from image

Thank you for completing our Individual & Family Health enquiry form.

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