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®

Simple and affordable healthcare cover

To join call us in Ennis on 1890 451 451
For all other enquiries please call 1890 473 473

Application Form – Direct Debit

Progress Tracker

If you have any questions, please feel free to call our service team on 1890 451 451.

^* Denotes mandatory fields.
^† Denotes mandatory only if applicable.

Cash plan selection Select the Health Cash Plan you want.
Personal details Enter your personal details as the main applicant for the scheme.
Spouse and dependant details Enter the details of other family members to be covered by the scheme (if applicable).
Medical details Enter any medical conditions you, your spouse or dependants may have.
Direct debit details Enter your bank details for a Direct Debit instruction to be made.
Confirmation A summary of your application and confirmation that your application has been submitted successfully.

Personal details Title^*: Forenames^*: Surname^*: Address^*: City/town^*: County^*: Postcode: Email address^*: Daytime Telephone No.^*: Mobile Telephone No.: Personal Public Service No. (PPS): [For Identification purposes only] Date of birth^*: [dd/mm/yyyy] Gender^*:

Male Female

Do you have a partner who is to be included within the scheme?^*:

Yes No

How many dependants (children under the age of 21) are to be included within the scheme?: Are you switching from another Health Insurer?^*

Yes No

Spouse and dependant details

Your partner's details (if applicable)

Title:^† Forenames^†: Surname^†: Date of birth^†: [dd/mm/yyyy]

Dependants' details
(children under the age of 21 – if applicable)

Dependant 1

Forenames^†: Surname^†: Date of birth^†: [dd/mm/yyyy]

Dependant 2

Forenames^†: Surname^†: Date of birth^†: [dd/mm/yyyy]

Dependant 3

Forenames^†: Surname^†: Date of birth^†: [dd/mm/yyyy]

Medical details

Why we collect this information

Your cover will be based on the information you supply on the whole of this application form. You must be satisfied that it is correct to the best of your knowledge and belief. To withhold or fail to disclose relevant facts (or to knowingly give false information) about the health and/or treatments of all persons to be covered could affect the benefits we are able to offer or could seriously influence your cover in the event of a claim. It could also lead to termination of cover or even be considered a criminal offence.

By completing health information on this form you will assist us in the administration of your policy. Failure to do so will not affect the registration.

What information you need to provide

Detail any medical conditions you, your partner or dependants have experienced by selecting a name then entering the relevant details. Clicking the ‘add conditions’ button will display the details on this page. To make a correction, click ‘remove condition’ link and enter the details again.

Applicant

Condition 1

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 2

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 3

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Partner

Condition 1

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 2

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 3

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Dependant 1

Condition 1

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 2

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 3

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Dependant 2

Condition 1

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 2

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 3

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Dependant 3

Condition 1

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 2

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Condition 3

Condition / illness: If ‘Other’ is selected, state the condition, illness or operation requiring treatment and any medication currently being taken: Date symptoms began: [dd/mm/yyyy]

Direct debit details

About Direct Debit

Direct Debits can now be set up on-line or over the telephone in addition to the original postal method.

All the normal Direct Debit safeguards and guarantees apply. No changes in the amount, date or frequency to be debited can be made without notifying you at least 10 working days in advance of your account being debited. In the event of any error, you are entitled to an immediate refund from your bank or building society.

You have the right to cancel a Direct Debit Instruction at any time simply by writing to your bank or building society, with a copy to us.

Your bank details

In order to set up your Direct Debit Instruction you will need to provide the following information (your cheque book contains all the bank details that you require):

Is the main applicant the account holder for the Direct Debit Instruction?^*

Yes No

Tick the box to confirm that the account can accept Direct Debits^*

Tick the box to confirm that you are authorised to allow Direct Debits to the account^*

Name of account holder^*: Branch sort code^*:

– –

Bank account number^*: Date each month for the above amount to be collected^*

5th 20th