Simply Health Enrolment Form

Simply Health Enrolment Form
Employee Details
Care Home/Location*
Name*

TitleFirst NameLast Name
Please complete the below if you wish your partner and/or children/dependents to be included in the Simply Health cover and ask your partner to sign where required below. By signing they are giving consent for their details to be held by Venturi Healthcare and used only in relation to the Simply Health cash plan. This information will not be shared with third parties.

Partner is defined as someone living at the same address. N.B. Any partner added is chargable. The current cost is £10.50 per month.

Child/Dependent is defined as under 21 years old and someone living at the same address; or up to the age of 24 if in full time education. Up to four children/dependents can be added - one claim limit to be split between all children/dependents.
Would you like to add your partner to your Simply Health plan?*
Partner Details:
Title:
Full Name:

First NameLast Name
Gender:
Date of Birth:

DayMonthYear
Date
Signature:
Would you like to add your children/dependents to your Simply Health plan?*
Child/Dependent Details:

Child/Dependent is defined as under 21 years old and someone living at the same address; or up to 24 years of age if in full time education
Child 1 Details:
Title:
Full Name:

First NameLast Name
Date of Birth:

DayMonthYear
Date
Would you like to add another child/dependent to your Simply Health plan?
Child 2 Details:
Title:
Full Name:

First NameLast Name
Date of Birth:

DayMonthYear
Date
Would you like to add another child/dependent to your Simply Health plan?
Child 3 Details:
Title:
Full Name:

First NameLast Name
Date of Birth:

DayMonthYear
Date
Would you like to add another child/dependent to your Simply Health plan?
Child 4 Details:
Title:
Full Name:

First NameLast Name
Date of Birth:

DayMonthYear
Date
Should be Empty:

Simply Health Enrolment Form

Employee Details

Partner Details:

Child/Dependent Details:

Child 1 Details:

Child 2 Details:

Child 3 Details:

Child 4 Details: