| Speciality: | |
| Sub speciality: | |
| Please indicate amount of coverage required: | |
| Group | |
| 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.
|
| Payment | |
| Total Premium | $
|
| First Installment | $
|
| Addtional Installments | $
|
| Clear Values |