Life Assurance Online is a site designed to help you obtain a cheap quote for Life Insurance, Critical Illness Insurance, Income Protection Insurance and other insurance products. All requests and information you provide through this site will be dealt with by Face to Face Finance (Anglia) Ltd which is regulated by the Financial Services Authority. They are able to research the whole UK life insurance market on your behalf.

This site is intended for UK residents and British expatriates only.

Private Medical Insurance Quote Form

This form caters for Private Medical Health Insurance for UK or International cover for both UK residents and British expatriates. If you require group cover for a company or organization please send your contact details including telephone number by email to rachel.pease@facetofacefinance.co.uk Please complete all fields highlighted in red to provide you with a quote.

Single

Partner

Title

First Name

Surname

Date of Birth

Male/Female

Smoker

Occupation

Address 1

Address 2

Town/City

County

Post Code

Telephone Number

When can we contact you on this telephone number?

Nationality

Country of Residence

Email Address

Do you have any existing private medical insurance cover?

How long since you had an overnight stay in hospital excluding stays for emergencies, maternity or chronic illness?

Do you exercise on a regular basis in any form?

Have you checked your cholesterol in the last 12 months?

Have you checked your weight in the last 12 months with a medical professional?

Number of dependents to be included (if any, please give details below)

	Age	Smoker	Married	In full time education
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5

Do want want a Voluntary Excess?

What does this mean?

Do you want a No Claims Discount on your plan?

What does this mean?

Would you prefer a plan which pays the benefit in cash to you?

What does this mean?

If 'Yes', please select amount of in-patient benefit

Do you require out-patient cover?

Do you want a UK only plan or one with International cover?

Priority response required?

Yes Not Urgent

How did you find us?

If you selected 'Search Engine', please specify

Additional comments

As a further service, we would like to keep you informed by email of new developments and activities in the insurance and financial planning markets, possibly in the form of a newsletter. If you would like to receive further information please select Yes on the pop up menu.

Please click on SEND once or CLEAR to re-enter.

Please note that quotations are subject to underwriting and premiums cannot be guaranteed until confirmed by the assurance company.