Health Insurance Fact Find

Code (For Offices Use Only)
Phone or Counter Call
The following details has been captured by one of our brokers with you over the phone.
The following details has been captured by one of our brokers with you you in our office.
Broker Name
Time Captured
Date Captured
How did the customer hear about us?

Other
Health Insurance Fact Find
Name

First NameLast Name
Your Date of Birth
Address

Street Address

Street Address Line 2

CityCounty

Eircode
Phone Number

Area CodePhone Number
Email
example@example.com
Do you currently have Health Insurance
Current Renewal Date
Current Insurer
Current Plan Name
Have you and additional members had continuous Health Insurance cover in Ireland since 30/4/2015?
Were you and additional members resident in Ireland on 30/4/2015
If not, when did you and additional members become a resident/s
Are you aware that there will be initial waiting periods for new conditions?
Are maternity benefits of interest to you?

Persons to be covered

Please detail if the following benefits are of importance to you:
Cover for public, private or high tech hospitals. Please select most relevant
Cover for routine medical expenses (e.g. GP visit) for you or your family?
What additional benefits would be of interest to you
Where did you hear about us?
To obtain you a Quotation we need your Consent
In order to obtain you a quotation we need your permission to submit your details provided to insurers to obtain you a quotation
Submission Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDateHourMinutes
Date of Submission

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty:

To obtain you a Quotation we need your Consent