Group Medical Scheme Application

By completing this form the details contained in this application will be passed to our MDDUS Solutions team for review. A Sales team member may be in touch, using the details you have provided, to discuss your application with you.

Required start date of Medical Group Scheme Name of Medical Business/Organisation Please detail the speciality or professional nature of your group/organisation Is the business located in the UK? Yes No Business website address (leave blank if you do not have a website) Business Tel No.

Point of Contact

Name Telephone Number Email

Consultant Details

How many consultants work in your medical business? How many of the consultants in your medical business/organisation do you expect to join the Medical Group Scheme?

Additional Details

Would you like to receive a quote for both our Medical Group Scheme Discretionary and Insurance Products?

Optional Benefits

Already have Medical Business Cover? Please tell us your reference number Would you like a quote or more details about Medical Business Cover? Yes No

Please note, you will be contacted by a BDE who may request additional information to provide pricing.