Opt-in Application Form. for associations, companies and groups. General & Medical

Size: px

Start display at page:

Download "Opt-in Application Form. for associations, companies and groups. General & Medical"

Bruce Kennedy
8 years ago
Views:

1 Opt-in Application Form for associations, companies and groups General & Medical

2 General & Medical Healthcare, providers of: Private Health Insurance for Individuals & Families Private Health Insurance for Companies & Groups - Company paid schemes - Voluntary or Opt-in schemes Private Health Insurance for Sports People & Clubs Sports Accident Insurance for Sports People & Teams Corporate Healthcare Trusts - Healthcare Trusts are provided and administered by our sister company, ProAmica Ltd - Trust establishment and administration - Administration only We do our part to help the environment by printing our documents in-house, enabling us to significantly reduce our paper waste. PEOPLE FIRST... always 2

3 Application for Opt-in Service Please complete this application to make the Opt-in service available to your staff or members. There is no charge for setting up the service. Your staff or members will benefit from online access to the full range of General & Medical covers at special rates, on a voluntary basis. Each person buying General & Medical Health Insurance will be responsible for their own premium payments. Part 1 - Basic information about your Company or Association 1 Name of Company or Association 2 Address 3 Telephone Number 4 Fax Number 5 Contact Person 6 Address 7 Company or Association website 8 How long has the Company or Association been established? 9 What is the nature of the Company or Association's business? 10 How many employees or members does the Company or Association have? 3 here to help at

4 Part 2 - Information about the person responsible for your Internet or Intranet site 11 Name 12 Address 13 Telephone Number 14 Do you operate a secure company intranet? Are you able to link from your intranet to an external internet site? Do you have.gif or.jpg versions of your company or associations logo that we can add to your secure area on our site? Part 3 - Information relating to the establishment of your Opt-in Scheme 15 From what date do you wish the service to become available? 16 Will the service be open to all your staff or members? 17 Do you have an existing company paid Health Insurance Scheme? If Who with? Who has access to it? 18 Do you require reports on take up? 19 Do you require commission to be paid to your company or association? If you answer yes to this question you must fill in an agency application form. Please also be aware that the amount of discount we can offer to your staff or members will be reduced if we are paying your company, association or broker commission. Please note that, with this service, if you are not a General & Medical registered broker, you are not authorised to sell our products. You may only introduce staff or members directly to General & Medical via the online service. PEOPLE FIRST... always 4

5 Part 4 - Please provide any further information you think will assist us in setting up your Company's secure area on the General & Medical website Part 5 - Broker Details 20 Do you have an appointed broker associated with this application? If Please supply the broker's name and address Name Address 21 Do you require commission to be paid to the broker? I declare that I have answered all questions truthfully and correctly. Signed Name Date On behalf of Please return your completed application to: General & Medical Healthcare, General & Medical House, Napier Place, Orton Wistow, Peterborough, PE2 6XN. 5 here to help at

6 For General & Medical Use only Received Site Link Completed Approved Approved By I.A.R. / Broker Terms & Conditions Received PEOPLE FIRST... always 6

7 tes: 7 here to help at

8 want to know more? please contact us on or or visit General & Medical Insurance Ltd. Registered in Guernsey rmandie House, Rue a Chiens St Sampson's, Guernsey GY2 4AE General & Medical Insurance Ltd are authorised and regulated by The Guernsey Financial Services Commission Administered by General & Medical Healthcare General & Medical House, Napier Place, Peterborough, PE2 6XN General & Medical Healthcare, a division of General & Medical Finance Ltd Registered in England General & Medical Finance Ltd are authorised and regulated by the Financial Conduct Authority - FCA which can be checked by visiting General & Medical Securities Ltd has a beneficial interest in General & Medical Insurance Ltd A-4002-V2.4

Sports Health Insurance. application form for clubs with 10 members or more

Sports Health Insurance. application form for clubs with 10 members or more Sports Health Insurance application form for clubs with 10 members or more Here to Help We hope you will find this application form easy and straightforward to complete but if you require any assistance