Corporate Health Insurance Enquiry Form

Simply complete the form below for a no obligation discussion and, if you wish, a detailed proposal. You must be authorised (have the consent of your employer) to submit this form.

On receipt of the details, we will contact you to discuss the range of options available to the employer and on request prepare a written proposal for a Corporate Health Insurance Plan for employees. There is no charge for this service. Should the employer wish to proceed with the Plan, we will work with the company to plan the launch of the Corporate Health Inusurance arrangement to employees.

All information received is treated as confidential (refer to our Privacy Policy)

Contact Details

Your Title

Your Name

Authorised Contact Title

Authorised Contact Name

Contact Phone

Fax Number

Business Address

Email Address

Business Details

Business Name

Business Type

Number of Employees

Number of Single Employees

Number of Couples Employees

Number of Family Employees

Payroll Frequency

If other please specify

Existing Health Insurance Plan

Do you have an existing Employer Health Plan?

If YES please fill in the details below. If NO skip to the next section

Name of Health Fund

Number of Employee Members

Does Employer subsidy apply?

Basis of Subsidy

Options for New Plan

Proposal Options

Proposed Level of Employer Support

Preferred Contact Basis

Preferred Follow-up Basis

Additional Information

Please provide any extra information or queries in this text box.