Request a Quote

Please note that this form is for individuals and families who do not currently have any cover in place, and are looking for a brand new policy. If you currently have cover and are looking for a review of the market, please contact us via email at with a copy of your current certificate of insurance so that we can make sure we review your cover on the correct basis.

Policyholder Full Name

Policyholder Address:


Date Of Birth:

Telephone Number:


Mobile Number:

Number person/s on policy:

Cover Region:
Hospital Network required (uk only):
Cover extension required:

Excess Required (£100 Excess Compulsory With Some Insurers):

Please enter below details of any dependants (a spouse or partner, or any children up to the age of 25) who are to be covered by the policy:

Name Gender Relation to
policy holder
Date of Birth


"I would like to take this opportunity to thank you and your team for your advice and support in arranging both our Death in Service and Private Medical Insurance cover. Premier Healthcare clearly have a great deal of knowledge and expertise in the healthcare field and it was re-assuring to know that we were in capable hands. My numerous requests for advice and information were dealt with promptly and efficiently and we are very grateful that you were able to obtain very competitive prices for both our schemes."
C Froude, Bristol