Quote For Individuals & Families : Enquiry Form

Quote For Individuals & Families

Fields marked with a * are required

Your Details

Your full name : *

Email address : *

Contact number : *

Mobile number (if different) :

Postcode : *

Your Insurance

Who is the cover for? : *

	Yourself only
	You and your spouse or partner
	you and your whole family

Please give ages of all persons you wish to cover:

You :

Your spouse or partner :

1st Child :

2nd Child :

3rd Child :

Excess amount : *

Do any of the people you have proposed have any existing medical conditions?

If so please detail them below:

Name :

Condition :

Date of last treatment :

Do any of the proposed people smoke? : *

	Yes
	No

Do you have existing private medical insurance? : *

	Yes
	No

If yes, who is it with? :

Date cover required / renewal date :

/ /

Details of your enquiry :

Please note : cover is not in force until confirmed by us

Contacting You

Preferred contact method :

Preferred contact time (monday - friday) :

233 Collingwood St Hamilton. PO Box 1009 Waikato Mail Centre, Hamilton 3240. | Freephone: 0800-500 113 | Email: sylvia@pic.co.nz