Health Insurance Fact Find

Code (For Offices Use Only)
Phone or Counter Call

PhoneVisit 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
How did the customer hear about us?

Call Back RequestedSocial Media CampaignEmail CampaignRadio CampaignSearch OnlineExisting CustomerOther
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*

YesNo
Current Renewal Date
Current Insurer

Irish Life HealthLaya HealthVHI
Current Plan Name
Have you and additional members had continuous Health Insurance cover in Ireland since 30/4/2015?*

YesNo
Were you and additional members resident in Ireland on 30/4/2015*

YesNo
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?*

YesNo
Are maternity benefits of interest to you?*

YesNo

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

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

YesNo
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

I ConsentI Do Not Consent
Submission Date

DayMonthYear
DateHourMinutes
Date of Submission

DayMonthYear
Date
Should be Empty:

To obtain you a Quotation we need your Consent