HCI Protector application form - hcigroupglobal.com

Who is making the application? *

Broker
Direct applicant

Are all policyholders under 65 and looking for medical insurance outside their country of nationality?

Yes
No

Great! Let's get you covered. We need to take a few details about your medical history to confirm your premium.

Unfortunately we are only able to cover expats or people living abroad. The maximium age we will cover is 64. Sorry we cannot help you today and thank you for your interest in HCI Group.

Area of cover *

Area 1
Area 2
Area 3

Area 1: All countries worldwide.

Area 2: All countries worldwide, excluding the USA and its outlying islands.

Area 3: All countries worldwide excluding the USA and its outlying islands, China, Greece, Guatemala, Honduras, Hong Kong, Israel, Jersey, Mexico, Russian Federation, Singapore, Switzerland and the United Kingdom.

Level of cover *

Emergency Plus
Standard
Plus
Premium
Executive

See the benefits for each level of cover.

Currency *

US dollar
Pound sterling
Euro

Deductible *

$0
$250
$1000
$2000

Deductible *

$0
$250
$1000

Deductible *

$250
$1000

Deductible *

£0
£170
£710
£1400

Deductible *

£0
£170
£710

Deductible *

£170
£710

Deductible *

€0
€210
€860
€1700

Deductible *

€210
€860

Deductible *

€0
€210
€860

Broker name and ID

Lead policyholder details

First name *

Last name *

Country of residence *

Address within country of residence *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

If this address has not yet been confirmed please provide the current home address.

Date of birth *

Metric / Imperial *

Height *

Weight *

Email address *

Nationality *

Phone *

Additional people to be covered

Cover for a partner / spouse? *

Yes
No

Name *

First

Last

Date of birth *

Nationality *

Metric / Imperial *

Height *

Weight *

Cover for dependents?

Yes
No

How many dependents do you want to cover?

Full name, date of birth, height and weight for all dependents

Please add each dependent on a new line.