General Insurance Intermediaries Specialising in Life and Health

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Request For Free Health Care Quotation

"FULL QUOTATION SERVICE"
listing premiums & benefits of comprehensive and budget plans

Fidelity Health Choice do not charge their clients fees as any remuneration they receive is paid by the insurers for whom they are authorised intermediaries.

Details will be sent to you with a pre-addressed envelope for return of the application form . If you decide to proceed direct debit instructions, cheques or credit card authorities are to be made payable to the insurer selected.

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Now Please Enter Your Details Below

Surname Address
Forename Town/City
Mr./ Mrs. /Other State/Province/County
Date of Birth Post Code
E-mail (Required)
 Country of Residence
Home Phone Country of Origin
Mobile Phone Fax
Work Phone

CURRENT INSURANCE
Do you presently have insurance cover? Yes No To what Date?
Preferred premium frequency Monthly Annually Current Premium
    Present Insurer

OTHER PERSONS REQUIRING COVER
(N.B The Date of birth is required for all persons to be insured)
Title, Initial, Name, D.O.B.
 Title, Initial, Name, D.O.B.
Title, Initial, Name, D.O.B.
 Title, Initial, Name, D.O.B.
My Status ... I am interested in the following...
Single Person
Married Couple
Single Parent
Voluntary Group
 Family
Company
Self Employed
Small/Medium Enterprise		 Private Med. Insurance
Income Protection
Critical Illness
Mortgage Protection		 Dental Cover
Medical expenses
Expatriate Cover
Life Insurance                     Travel Insurance

ARE YOU A SMOKER? No      Yes

ARE YOU LOOKING FOR COMPREHENSIVE OR BUDGET COVER?   Comprehensive    Budget

WOULD YOU CONSIDER A VOLUNTARY EXCESS FOR A LOWER PREMIUM? No       Yes

Other comments or questions

IMPORTANT:
if you have any pre-existing medical condition or are receiving treatment now or in the recent past, you should enter details in this section. Please use this box for any questions that you may have for us:-

 

WHERE DID YOU DISCOVER THE FIDELITY HEALTH CHOICE WEBSITE (SEARCH ENGINE, ETC.)

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