Coronis International Ltd

+44 1403 262652

Health Assistance Programme Membership Application Form for Individuals

For corporate membership please email or call +44 1403 262652

EXPATRIATE OPTIONS

LOCAL NATIONAL OPTIONS

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

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

Family Name *
First Name *
Date of Birth
Gender	Male Female
Nationality
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