Health Insurance Proposal Form
PLEASE ANSWER ALL QUESTIONS HONESTLY, ACCURATELY AND TO THE BEST OF YOUR KNOWLEDGE.

The answers you provide will form the basis of your insurance quotation. If you are unsure about what is relevant, please let us know as it may influence the insurer’s decision to accept the risk or could impact the terms of cover.

If you fail to disclose or misrepresent any information, this could invalidate the policy and mean that claims may not be paid or not paid in full. Any deliberate or reckless non-disclosure may mean that the insurer can void the policy and retain the premium. This applies when you take out a policy, during the term of the policy and when you renew.
Sign in to Google to save your progress. Learn more
Email *
I'd like to receive updates, news and offers from Yellow Bolts by email. You can unsubscribe at any time.
1. Applicant Details
Please provide your personal details.
Full name *
Date of birth *
MM
/
DD
/
YYYY
Gender *
Full Address including Post Code *
Occupation
Phone number *
Smoker status *
2. Who Needs Cover?
Tell us who you would like included on the policy.
Who needs cover? *
How many people need cover in total? *
Please enter a number.
Please list the full names and dates of birth of any additional people to be covered
One person per line is fine.
3. Current Insurance
Please tell us if you currently have health insurance.
Do you currently have private health insurance? *
If yes, who is your current insurer?
If applicable, what is your renewal date?
MM
/
DD
/
YYYY
If known, what type of underwriting do you currently have?
Clear selection
4. Medical Background
We only need a high-level view at this stage to guide the quotation.
Do you currently have any ongoing medical conditions? *
If yes, please briefly provide details
Have you had any treatment, tests, or investigations in the last 5 years? *
If yes, please briefly provide details
Height
For example: 175 cm or 5 ft 9 in
Weight
For example: 75 kg or 11 st 11 lb
5. Cover Preferences
Please tell us what is most important to you.
What matters most to you? *
Required
Preferred monthly budget
Clear selection
Preferred excess
Clear selection
Preferred outpatient cover
Clear selection
Preferred hospital access
Clear selection
Is full cancer cover important to you?
Clear selection
Is mental health cover important to you?
Clear selection
Are therapies such as physiotherapy important to you?
Clear selection
6. Lifestyle and Rewards
This helps us understand whether rewards-led products may suit you.
Do you exercise regularly?
Clear selection
Would you be interested in rewards-based cover, such as gym discounts or wellness incentives?
Clear selection
7. Timing
Please tell us when you need cover to start.
Preferred start date
MM
/
DD
/
YYYY
Are you looking to replace an existing policy?
Clear selection
8. Next Steps
Let us know how you would like us to follow up.
How would you prefer us to contact you? *
Best time to contact you
For example: mornings, afternoons, after 5pm
Anything else you would like us to know?
Declaration
Please confirm *
Required
When do you want cover to start? *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms