Fidelity Health - Health Insurance Company - Independent Health care advisers

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

* Denotes Mandatory Fields

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

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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

ARE YOU A SMOKER? No Yes

LEVEL OF COVER REQUIRED? Comprehensive Mid-Range Budget

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