Private medical insurance quotation
Your age band
18-25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Smoker
Non Smoker
Not a member of Gym
Gym/ Health Club member
Partner's age band
N/A
18-25
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
Smoker
Non Smoker
Not a member of Gym
Gym/ Health Club member
Child 1 Age Band
N/A
0-17
Children will normally be in full time education
Child 2 Age Band
N/A
0-17
and living with you or going to college for the
Child 3 Age Band
N/A
0-17
term and coming home in the vacations. If 18 or
Child 4 Age Band
N/A
0-17
over a separate policy will be needed
(Once on the policy a child can be covered up to age 25 at child rate if unmarried and in full time education)
Hospital Band
All UK Hospitals covered - standard single en-suite room where available
Declaration I have completed the form to the best of my knowledge and belief. I have made a full disclosure of all material facts. I have read and understood the Important information below. I understand that there is no cover in force until confirmed by B. Portwood & Co Ltd, a satisfactory proposal form completed and accepted and payment of the premium made - either in full or an instalment plan set up acceptable to B. Portwood & Co Ltd.
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