• WHA Direct Application Form

    Simply fill out this form to join the WHA Direct Cash Plan with voluntary payroll deduction, and we'll coordinate the details with your employer.

  • Important

    Please read the Insurance Product Information Document and the Benefit & General Conditions before completing the form, and tick to confirm. For questions, call 02920 485461 or email enquiries@whahealthcare.co.uk

  • Your Details

  • Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • How often are you paid?
  • Do you wish to include your partner on this policy?*
  • Your Partners Date of Birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Choose your Individual Plan*
  • Choose the Plan for You and Your Partner*
  • Your Policy Start Date
     - -
    2 digit day, 2 digit month, 4 digit year

  • Consent / Signature

  • Consent Date*
     - -
    2 digit day, 2 digit month, 4 digit year

  • Assessing your Demands & Needs for the WHA Direct Policy

    Would you (and your partner, if applying for a joint policy) benefit from financial assistance towards a range of health care costs now and in the future, e.g. costs incurred for optical care, dental treatment, physiotherapy, osteopathy, chiropractic, acupuncture, chiropody, hospital inpatient or outpatient visits.
  • Please tick the appropriate response*

  • We’re unable to proceed with your application as you’ve indicated that the cash plan may not be beneficial to you. Please review the policy information again to ensure you fully understand what’s included and how it could support you.

  • Data Protection & Marketing Preferences

    We will use the information you provide to us on this application for the purposes of providing you with your insurance policy, underwriting and administering your policy and processing any claims. Please tick if you would like to receive information about our products and any special offers:
  • Please tick the appropriate response*

  • Tell us who referred you

  • Please provide the details of the WHA policyholder who recommended us to you. We’ll use this information to confirm the referral. Please make sure you have their permission to share these details with us. Their policy number can be found on their WHA policy documents or correspondence. Terms and conditions apply. View the Refer a Friend terms and conditions.

  • Your Bank Account Details

    Please provide us with the account you would like your claims to be paid to
  • Bank Account Number*
  • Sort Code*

  • Payroll Deduction Consent

  • I authorise Carmarthen County Council to deduct* from my pay each month and remit this amount to WHA Healthcare. I understand that I may cancel this authorisation at any time by providing one month's written notice to my payroll department. This authorisation replaces any previous instruction given in respect of WHA Healthcare.

  • I authorise Carmarthen County Council to deduct* from my pay each week and remit this amount to WHA Healthcare. I understand that I may cancel this authorisation at any time by providing one month's written notice to my payroll department. This authorisation replaces any previous instruction given in respect of WHA Healthcare.

  • Consent / Signature

  • WHA Healthcare is a trading name of Welsh Hospitals & Health Services Association, a Limited Company Registered in Wales. No. 515135. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. No. 202605.

    We will always take legal and/or police action against anyone who makes a dishonest, false or fraudulent claim.

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