Health Cash Plan
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Full Company PMI Fact Find
Company Name *
Type of Business
Contact Name and Title:
Number of Employees
All the main members applying for cover are employees of the company
Please list and number the names and dates of birth of the employees / Main Members?
If you cannot complete this then please either email us a spreadsheet of the details or scan and email a copy of the current membership statement with these details which will be provided by your current provider. This can be emailed to firstname.lastname@example.org
Please list the names and dates of birth of spouses and or partners and number accordingly to the main member above
Please list the names and dates of birth for any dependents under the age of 25 and who live with their parents or are in full time education. Please specify which number above they belong to
Current PMI Insurer Details or Desired Cover for new schemes
Renewal Date or Preferred Start Date
What are the last 3 years premiums you have paid as a business? We need this information to work out the loss ratio on the policy?
What type of underwriting is stated on your current membership statement or medical certificate? Underwriting may differ per member, please specify?
Excess Level Required
Different Excess levels of individuals
Reduced Outpatient Cover (for certain members on the scheme such as non directors or alternative employees)
Full Cancer Cover
Alternative Therapies (physiotherapy/osteopathy/chiropractic cover etc...)
Outside of London (Not including Central London but possibly outskirts of London)
London (All main London Hospitals except the TOP 6-10 in London)
Premier List (including all on list)
Are retirees covered?
Are there any plan members or group leaver to consider?
Have any OAD’s been identified at renewal? If so please provide detail
Please confirm that all members are eligible to be on this scheme?
Main member must be employed by the company; spouse/partner/dependents must be covered under the main member’s registration unless they are also employed by the company.
Demand and Needs
Is the client happy with the existing insurer?
Reasons why they might like to change insurer (if possible)?
Desire to change payment frequency? *
Please specify preferred payment frequency
Would client consider an excess change *
How much excess?
Does the client have a preference for a particular hospital or list? *
If applicable, please specify client requirements
If applicable, would the client consider a change in hospital network? *
Hospital network details
Would client consider a change in cover? *
Change in cover details
CLAIMS/TRANSFER CRITERIA ISSUES (please provide full details including member and condition)
IF THE ANSWER TO ANY OF THE BELOW IS YES, please provide as much info as possible, the name of the person, the condition, treatment received or still receiving and dates when the treatment was carried out if treatment is no longer being received. * NOTE: If applicable, please take care to enquire of any particular consultant/specialist being required.
Has any employee or family member who has (in the last 2 years) seen a GP or other healthcare professional or received treatment (including ongoing medication) for any of the following conditions?
Heart or Stroke condition including hypertension, angina and heart attacks
Any form of Cancer
MSK – including back or joint problems
Organ failure or transplants
Psychiatric, or mental, illness or condition
Are you aware of any person to be covered by this application including spouse, partners or dependents who in the last 12 months have received treatment or advice from a GP, hospital or specialist, either privately or via the NHS? If so, please provide details along with the date?
Has anyone to be insured on this plan has been diagnosed with or received any form of treatment/consultation for cancer in the past 12 months?
Are you aware of any person to be covered by this application/policy including spouse, partners or dependents who has a medical condition that is likely to result in the need for an in-patient stay in hospital?
Or any out-patient treatment pending/arranged?
Terms of Business
has been sent to client?