Health Insurance

Hi, to get started, can I have your first name?

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What is your date of birth?

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Month

Year

Great, what is your postcode?

What is your phone number?

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What date would you like your cover to start?

Day

Month

Year

Non Smoker Smoker Quit less than 6 months ago Quit less than 1 year ago Quit less than 2 years ago Quit less than 3 years ago Quit over 3 years ago

Do you currently have a health insurance policy?

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Is your existing policy a group/company scheme?

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Do you wish to add your partner to your quote?

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What is your partner's first name?

What is your partner's surname?

Is your partner:

Male Female

What is your partner's date of birth?

Day

Month

Year

Does your partner smoke?

Non Smoker Smoker Quit less than 6 months ago Quit less than 1 year ago Quit less than 2 years ago Quit less than 3 years ago Quit over 3 years ago

Would you like to add any children to your quote?

None One Child Two Children Three Children Four Children Five Children

Is your first child:

Male Female

What is your first child's date of birth?

Day

Month

Year

Is your first child in full time education?

Yes No

Is your second child:

Male Female

What is your second child's date of birth?

Day

Month

Year

Is your second child in full time education?

Yes No

Is your third child:

Male Female

What is your third child's date of birth?

Day

Month

Year

Is your third child in full time education?

Yes No

Is your fourth child:

Male Female

What is your fourth child's date of birth?

Day

Month

Year

Is your fourth child in full time education?

Yes No

Is your fifth child:

Male Female

What is your fifth child's date of birth?

Day

Month

Year

Is your fifth child in full time education?

Yes No

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