Underwritten Group Scheme Application Form

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.

If you are a group scheme member who pays for all or part of your healthcare premium, and you choose to pay by Direct Debit, please complete and submit the appropriate Direct Debit Mandate below.

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.

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Dental questionnaire

If you are seeking dental cover and answered 'Yes' to any dental question in the health declaration section of the Application Form, please complete and return this questionnaire.