Allied Healthcare Contact Form

Title

Forename

Surname

Postcode If you are a resident in Gibraltar unfortunately the automatic address system does not work correctly, please enter your address details manually below

Address Line 1

Address Line 2

Address Line 3

Address Line 4

Email address

Contact number

Your company or other entity name / trading name (if applicable)

Are you qualified or a student/trainee?

QualifiedStudent/Trainee

Are you a member of a professional association for your work?

YesNo

Please provide the name of your primary association. If the association you are a member of is not on this list, please select “Other” and provide the name in the “Additional Associations” box below

Please provide your membership number

Additional Associations

What is your occupation for which you require this quote?

HCPC Registration Number (if applicable)

Have you had any complaints or claims made against you; or are you aware of any circumstances that are likely to give rise to a claim?

YesNo

Please provide details of all claims or circumstances that are likely to give rise to claims?

Have you ever had insurance declined, or has an insurer refused to renew or terminated any liability insurance?

YesNo

Please provide details of insurance declinatures or cancellations?

If you choose to accept the quote when would you like cover to start (not a requirement at this stage)

Where/how did you hear about us?

I confirm I have read and agree to the Terms of Business and Privacy and Data Protection policies.

Insurance Quote Questionnaire