Health Insurance Fact Find

Code (For Offices Use Only)
Phone or Counter Call

Phone Visit to our offices
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
Health Insurance Fact Find
Name *

First Name Last Name
Your Date of Birth *
Address *

Street Address

Street Address Line 2

City County

Eircode
Phone Number *

Area Code Phone Number
Email *
example@example.com
Do you currently have Health Insurance *

Yes No
Current Insurance Details
Current Renewal Date
Current Insurer

Irish Life Health Laya Health VHI
Current Plan Name
No Previous Insurance
Are you aware that pre-existing conditions are not covered if you have not held insurance previously? *

Yes No
Are you aware that there will be initial waiting periods for new conditions? *

Yes No
Are maternity benefits of interest to you? *

Yes No

Persons to be covered

Name

DOB

Type

Cover Level

Please detail if the following benefits are of importance to you:
Cover for public, private or high tech hospitals. Please select most relevant

Public Private High Tech
Cover for routine medical expenses (e.g. GP visit) for you or your family?

Yes No
Is there a particular benefit that you would like cover for?

Yes No
What additional benefits would be of interest to you
Promo Code
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

I Consent I Do Not Consent
Contact Preferences
Please confirm we can contact you by email, telephone, SMS or post with quotations or in respect of any policy you hold with us.

Email Post Phone SMS
Marketing Consent

From time to time we may also send you communication in relation to other products or services we offer. We never share your email address with any other parties. Please confirm that it is OK to send you marketing information from Sheridan Insurances. Please choose below.
*

I Consent I Do Not Consent
Submission Date

Day Month Year
Date Hour Minutes
Should be Empty:

To obtain you a Quotation we need your Consent