Your Choice for Life

International Private Medical Insurance

Thank you for requesting a quotation via Internet.

At Swiss Insurance Partners, we choose only among the best, carefully selected medical plans to suit your particular situation. We offer more health plans from more insurers than any other broker worldwide. Individuals worldwide rely on us for professional advice and assistance in this delicate area where our expertise and experience are second to none.

This form is designed for your convenience and to handle your request most efficiently. Please tick the appropriate boxes and fill in the relevant fields according to your individual needs.


Contact information
Salutation*
First name*
Last name*
Telephone number (incl. country code)*
E-mail*
Confirm e-mail*
Nationality*
New Country of Residence*
Preferred correspondence language*


Insurance details
How many persons to be insured
Specify duration to be insured
Does any of the persons to be insured
have pre-existing conditions?*		 yes no
Do you take any kind of medicine on a
regular basis?*		 yes no
Have you been hospitalized in the last
ten years?*		 yes no
Are you currently insured? yes no


Do you have any specific questions?


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How did you find us?
Please let us know how you found or heard about us. Thank you!
 
I was referred by (please indicate who recommended us to you)
By AWD
I searched on the Internet. I used the following search engine
I saw an advertisement (please specify where)
I read an article in (please specify publication)
Other (please specify)



*required information

Important Note: All information is treated with highest confidentiality once received by us. However, data contained in this form may be viewed by third parties while in transit. For maximum information security print this form and send it by fax or mail.

Due to international differences in legislation and regulatory constraints, Swiss Insurance Partners make no warranty of any kind, express or implied, regarding the availability of any product or insurance scheme in any country.