Private Health Insurance
Account holder details
Title
Full Name
Address 1
Address 2
Post Code
Telephone Number
Email Address
Date of Birth
Gender
Male
Female
Marital Status
Choose...
Single
Married
Divorced
Occupation
Have you lived abroad in the last 5 years?
Yes
No
If Yes, please provide country and purpose
Partner details
Title
Full Name
Date of Birth
Gender
Male
Female
Children under 21 years living at the address above
Title
Full Name
Date of Birth
Gender
Male
Female
Title
Full Name
Date of Birth
Gender
Male
Female
Title
Full Name
Date of Birth
Gender
Male
Female
Title
Full Name
Date of Birth
Gender
Male
Female
Title
Full Name
Date of Birth
Gender
Male
Female
Your choice of account
Individual
Couple
Individual plus children
Couple plus children
Your monthly premium
If you're under 50 the minimum is £20 a month for an Individual account, £40 a month for Couples or Individual plus children.
If you're 50-68 the minimum is £50 a month for an Individual account, £80 a month for Couples or Individual plus children.
£20
£40
£50
£80
£100
£120
Other (max £200 per month)
Others Please Specify
Payments will be taken on the 1 st of each month and you will be covered as soon as we have processed your application.
Alternatively, please provide a start date
By completing this form, you have not yet purchased any Private Medical Insurance.
A member of Warren & Co will contact you in the next 48 hours to discuss this information with you
and send the necessary documentation.
I/we give permission for Warren & Co to contact us with reference to the information we have given on this application form.
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Warren & Co (Independent Mortgage Specialists) Ltd,
54 Dinglewell, Hucclecote, Gloucester GL3 3HU
01452 547783
