Apply Online (Private plans) 2020

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Apply now - Private Health Cash Plan (new 2020)

Step 1 of 3

Your details
Title
Gender*
Date of Birth*
DD slash MM slash YYYY
Why do you need my gender and date of birth?
We need this in order to identify you and check eligibility for cover.
Why do you need my gender and date of birth?
We need this in order to identify you and check eligibility for cover.
Why do you need my gender and date of birth?
We need this in order to identify you and check eligibility for cover.
Why do you need my gender and date of birth?
We need this in order to identify you and check eligibility for cover.
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City ZIP / Postal Code
This field is hidden when viewing the form
GDPR- personal details
Why do you need my contact details?
We need this in order to identify you and communicatewith you.
Why do you need my contact details?
We need this in order to identify you and communicatewith you.
Why do you need my contact details?
We need this in order to identify you and communicatewith you.
Why do you need my contact details?
We need this in order to identify you and communicatewith you.
How and why are you going to contact me?
We will need to make contact with you for the purpose of administrating your Paycare cover. Our preferred method of contact is email, and we will use this as default if no other preferences are set. You are can amend your contact preferences at any time at: paycare.org/my-paycare Our Privacy Notice can be viewed at: paycare.org/site-map/privacy
How and why are you going to contact me?
We will need to make contact with you for the purpose of administrating your Paycare cover. Our preferred method of contact is email, and we will use this as default if no other preferences are set. You are can amend your contact preferences at any time at: paycare.org/my-paycare Our Privacy Notice can be viewed at: paycare.org/site-map/privacy
How and why are you going to contact me?
We will need to make contact with you for the purpose of administrating your Paycare cover. Our preferred method of contact is email, and we will use this as default if no other preferences are set. You are can amend your contact preferences at any time at: paycare.org/my-paycare Our Privacy Notice can be viewed at: paycare.org/site-map/privacy
How and why are you going to contact me?
We will need to make contact with you for the purpose of administrating your Paycare cover. Our preferred method of contact is email, and we will use this as default if no other preferences are set. You are can amend your contact preferences at any time at: paycare.org/my-paycare Our Privacy Notice can be viewed at: paycare.org/site-map/privacy
Medical details
Medical History
- There are no pre-existing medical conditions to declare
- One or more of the people covered by this application has a medical condition or symptoms that may need medical consultation or treatment in the future
If so, please describe their name and describe the medical condition and/or symptoms
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Please select one box only.
- I have no pre existing medical conditions to declare.
- I have a medical condition or symptoms that may need medical consultation or treatment in the future.
This field is hidden when viewing the form
Please enter description of medical condition or symptoms below
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GDPR- medical details
Why do you need my medical history?
We need this in order to identify you and check eligibility for cover. We also use this data for anonymised internal data analysis.
Why do you need my medical history?
We need this in order to identify you and check eligibility for cover. We also use this data for anonymised internal data analysis.Our Privacy Notice can be viewed at:paycare.org/site-map/privacy
Why do you need my medical history?
We need this in order to identify you and check eligibility for cover. We also use this data for anonymised internal data analysis.Our Privacy Notice can be viewed at:paycare.org/site-map/privacy
Why do you need my medical history?
We need this in order to identify you and check eligibility for cover. We also use this data for anonymised internal data analysis.Our Privacy Notice can be viewed at:paycare.org/site-map/privacy
This field is hidden when viewing the form
Direct - Terms
*
- I have read and understand fully the Privacy Statement, IPID and Policy Documents. View full Policy document
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Family - Terms
*
- I have read and understand fully the Privacy Statement, IPID and Policy Documents. View full Policy document
This field is hidden when viewing the form
Under 25s - Terms
*
- I have read and understand fully the Privacy Statement, IPID and Policy Documents. View full Policy document
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Gold - Terms
*
- I have read and understand fully the Privacy Statement, IPID and Policy Documents. View full Policy document
Please note there is a Waiting Period of thirteen weeks from the commencement of cover, except for New Child Payment where there is a 12 month Waiting Period. During this time you will not be eligible to claim any Benefits.

Bank details
These details enable us to pay claims directly into your bank account.Your details are safe on our SSL certified secure server.
Sort Code*
Account Number*
Bank name*
Branch*
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bank details
Why do you need my bank details?
We need this in order to pay claims into your bank account. You bank details are stored safely and securely by Paycare.
Why do you need my bank details?
We need this in order to pay claims into your bank account. You bank details are stored safely and securely by Paycare.
Why do you need my bank details?
We need this in order to pay claims into your bank account. You bank details are stored safely and securely by Paycare.
Why do you need my bank details?
We need this in order to pay claims into your bank account. You bank details are stored safely and securely by Paycare.
Additional details
Congratulations! You get one month for free.
Do you have a promotional code?
How did you hear about Paycare?
You have chosen 'Other', please give details in the box below:*
You chose Direct Level 1 : £7.24 per month
You chose Direct Level 2 : 14.47 per month
You chose Direct Level 3 : £21.71 per month
You chose Direct Level 4 : £28.89 per month
You chose Direct Level 5 : £43.36 per month
You chose Family Level 1 : £35.64 per month
You chose Family Level 2 : £71.28 per month
You chose Go (under 25's) Level 1 : £6.05 per month
You chose Go (under 25's) Level 2 : £12.10 per month
You chose Gold (over 64's) Basic Plan : £25.91 per month
You chose Gold (over 64's) Basic Plan with Optional hospital: £35.75 per month
*
- I declare, on behalf of everyone covered by this application, that all the information that I have given is, to the best of my knowledge and belief, accurate, true and complete. I have read and understand fully the Privacy Statement, IPID and Policy Documents and have had the opportunity to raise any queries with Paycare. I agree to abide by the Policy Rules.
Name
This field is for validation purposes and should be left unchanged.

Looking for a company paid plan?

Apply now - Private Health Cash Plan (new 2020)

Step 1 of 3

Your details

Why do you need my gender and date of birth?

Why do you need my gender and date of birth?

Why do you need my gender and date of birth?

Why do you need my gender and date of birth?

GDPR- personal details

Why do you need my contact details?

Why do you need my contact details?

Why do you need my contact details?

Why do you need my contact details?

How and why are you going to contact me?

How and why are you going to contact me?

How and why are you going to contact me?

How and why are you going to contact me?

Medical details

GDPR- medical details

Why do you need my medical history?

Why do you need my medical history?

Why do you need my medical history?

Why do you need my medical history?

Direct - Terms

Family - Terms

Under 25s - Terms

Gold - Terms

Bank details

bank details

Why do you need my bank details?

Why do you need my bank details?

Why do you need my bank details?

Why do you need my bank details?

Additional details