Orbis 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*

12345678910111213141516171819202122232425262728293031  Day JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  Month 1900190119021903190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014  Year

Occupation*

Smoker Status*

Yes  No

Policy Information

Type of Policy*

Select OneLevel life Decreasing lifeMortgage protectionIncome protectionFamily Income BenefitCritical IllnessOtherMore than one of the above

Single or Joint*

Single  Joint

Number of years*

1 - 40  N/A  Other

Medical Information

Proposer 1

Name of medical condition*

Date of diagnosis*

12345678910111213141516171819202122232425262728293031  Day JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  Month 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021  Year

Details of hospital treatment*

Additional conditions

Proposer 2

Name of medical condition (Proposer 2)

Date of diagnosis (Proposer 2)

12345678910111213141516171819202122232425262728293031  Day JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember  Month 1970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021  Year

Details of hospital treatment (Proposer 2)

Additional conditions (Proposer 2)

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