Health Assistance Programme Membership Application Form for Individuals

For corporate membership please email or call +44 1403 262652



Accidental Death Benefit USD $25,000 *
* Sum insured can be increased on request; please ask for details.

Family Name *
First Name *
Date of Birth
Gender Male   Female
Address Line 1 *
Address Line 2
City *
County *
Postcode *
Home Country *
Telephone Number *
Email Address *
Start Date of Membership
Employer *
Nature of Employment *
Start Date of Employment
Spouse Name
Spouse DOB
SpouseGender Male   Female
Child 1 Name
Child 1 DOB
Child 1 Gender Male   Female
Child 2 Name
Child 2 DOB
Child 2 Gender Male   Female
Child 3 Name
Child 3 DOB
Child 3 Gender Male   Female
Have any of the applicants
received medical treatment,
or taken medication,
in the last 12 months?
 (tick for Yes)
Medical Treatment Details
*Required Fields

Coronis (International) Ltd, PO Box 588, Horsham, West Sussex RH12 5WJ England
+44 (0) 1403 262 652 email:

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