If you are an individual applicant and wish to make payment via Visa or Mastercard please complete the Online Application Form
. However, if you wish to make payment via cheque or bank transfer or if you are a member of an Allianz Worldwide Care underwritten group scheme, please complete and return the PDF form below.
If there is not sufficient space on the form for all your dependants, please use a second form. Once you have signed the form, please mail it to Allianz Worldwide Care at the address given on the form.