Application Form for International Healthcare Plans

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 Partners at the address given on the form.

Application Form

If you choose to pay by Direct Debit, please complete and submit the appropriate Direct Debit Mandate as outlined below. Please note that quotes remain unchanged if you choose to pay by Direct Debit.

For payment in Euro, please complete the SEPA Direct Debit Mandate

For payment in Sterling, please complete the GBP Direct Debit Mandate

For payment in Swiss Franc, please complete the CHF Direct Debit Mandate