Sub speciality:
Please indicate amount of coverage required:
Basic Premium
Do you practice overseas? If yes please select the country:

Overseas coverage adds 25% to your premium.

Do practice any of the following :

Laser surgery adds 15% to your premium.

Laproscopic surgery adds 20% to your premium.

Health tourism adds 100% to your premium.

Proposed commencement of Policy
Is this a new policy or a renewal?

New policy Renewal / Reinstatement

Is your policy Lapsed

Yes No

A lapsed policy adds 40% to your basic premium.

Total Premium
First Installment
Addtional Installments
Clear Values