Abbeygate Health Insurance Quotation Request
Details of Proposer
Name Date of Birth 

    Where did you hear about us ? 
Insurance Details
Gender   Male     Female
Quote for   Myself    Myself and my partner
Partners Date of Birth     Age
Number of children (under 21)
Please confirm Gender & Date of Birth of each other traveller
Age Age Age Age Age
Select area of cover
 Europe         Country of Residence only
 Worldwide    Worldwide excluding USA and Canada
Additional cover
How would you like us to reply to you?
  Email   Post   Phone
Do you currently have health insurance cover?
  Yes     No
If so, with whom?
Would you like details of our Company health plan ?


Intended principal country of residence


This is the country where you intend to live for more than 6 months in any one year. Please note, this is not your country of origin.

Queries or Comments

How do you prefer to make payment
 Monthly   Annually