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


E-Mail Address*

Contact Tel No*




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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