Assure-U Ltd - Private Medical Insurance

Individual Health Insurance

Contact Details

Title

First name

Surname

Phone

Mobile

Fax

Address Details

Postcode:

Additional Details

Do you have existing health insurance?

YesNo

Current Provider

Current Scheme

Current Excess

Renewal Date

/ / (dd/Month/yyyy)

Last Year’s/Current Premium (if known)

Renewal Premium (if known)

Would you consider excess?

6 Week Option

YesNo

Number of years No Claims Discount (NCD)?

Type of Policy you require

Budget £:

Per AnnumPer Month

Protected NCD

YesNo

Personal Details

Please choose type of policy you required:

SingleCoupleFamilySingle Parent Family

Please select number of people to be included in the cover

Terms and Conditions

Please confirm that you have read and accept our privacy policy and terms of use

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Assure-U Ltd is Authorised and Regulated by the Financial Services Authority, Registered in England 5682094
Registered Office: Three Elms Office, Harts Lane, Ardleigh, Colchester,Essex, CO7 7QH | Tel: 0800 411 86 86 | Fax: 0870 974 90 70