Please enable JavaScript in your browser to complete this form. - Step 1 of 2Who 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 IDLead policyholder details First name *Last name *Country of residence *Address within country of residence *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryIf this address has not yet been confirmed please provide the current home address. Date of birth *Metric / Imperial *Metric (cm/kg)Imperial (ft/lbs)Height *Weight *Email address *Nationality *Phone *Additional people to be covered Cover for a partner / spouse? * Yes No Name *FirstLastDate of birth *Nationality *Metric / Imperial *Metric (cm/kg)Imperial (ft/lbs)Height *Weight *Cover for dependents? Yes No How many dependents do you want to cover? 12345+Full name, date of birth, height and weight for all dependentsPlease add each dependent on a new line. NextHas anyone to be covered on this policy been treated or diagnosed for a medical condition in the last 15 years for anything other than colds, flu, or routine checkup? (Routine checkup is defined as a physical exam and / or blood test that are of a routine nature and not used to treat a medical condition). * Yes No Please select any conditions that have been diagnosedHeart / Blood vesselsMental / Nervous disorderStrokeBlood pressureHypertensionCancerRespiratory problems (including Asthma) Diabetes (and related problems) HIV / AIDS or related diseasesOrthopaedic problems and arthritis (back, joints etc)Urinary disorders (including bladder, kidney, prostate, urinary infections and incontinence)Gynaecological disorders (including heavy or irregular periods, endometriosis, infertility, fibroids, abnormal smears and polycystic ovaries)Neurological disordersStomach / IntestineHerniaEars / EyesImmune System DisordersSexually Transmitted InfectionsSkin ThyroidAre any inpatient or outpatient medical/surgical or dental procedures or oral surgery (including diagnostic testing) recommended/contemplated for anyone to be covered on this policy? * Yes No Please provide detailsIs anyone to be covered on this policy experienced any symptoms of any medical problem in the last 12 months, regardless of whether a healthcare professional has been consulted? * Yes No Please provide detailsIs anyone to be covered on this policy currently taking any medication? * Yes No Please provide detailsHas anyone to be covered on this policy had an application or an application for reinstatement of Life, Accident, or Health Insurance declined, postponed, rated or modified? * Yes No Please provide detailsIs anyone to be covered on this policy pregnant? *YesNoWho is pregnant? Policy start date *Submit application