Life Insurance

If you have been diagnosed with a medical condition, whether it is recently or in the past, you may find it difficult to obtain life insurance. You may have an occupation that prevents you from getting a quotation via the regular channels.

Orbis have negotiated specialist rates with our insurers so that we are able to provide the majority with a comprehensive insurance policy.


Proposer Information


Name*

E-Mail Address*

Contact Tel No*

Address*

D.O.B*
     

Occupation*

Smoker Status*
    

Policy Information

Type of Policy*

Single or Joint*
    

Number of years*
     

Medical Information

Proposer 1

Name of medical condition*

Date of diagnosis*
     

Details of hospital treatment*

Additional conditions

Proposer 2

Name of medical condition (Proposer 2)

Date of diagnosis (Proposer 2)
     

Details of hospital treatment (Proposer 2)

Additional conditions (Proposer 2)
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Life Insurance

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