To provide you with a free quote, we’ll need some information to get started. Please tell us a little bit about yourself and your family including your preferred coverage, and we’ll come up with a few options that best fits your needs.

If you’re unsure about some of the options in this form, fill out the form as best you can and add a note in the message field and one of our advisors will contact you shortly.


First name
Family name
Date of birth
Pre-existing conditions
Contact Number*
Email Address*
If we need to contact you what is the preferred method and time of day?
Spouse First Name
Spouse Family Name
Date of birth
Pre-existing conditions
Children to be insured
Age of Child
Child 1
Child 2
Child 3
Area of Cover
Additional Benefits
MaternityDentalOpticalHealth Checks
Type of Cover
High Cost Providers
Excess / Co-payments
Any notes or further information you may feel is necessary:
Annual Budget and Currency
Current or Previous Insurer
Current or Previous Price
Intended date of commencement
 I agree to terms and conditions


Pre-existing medical conditions: A pre-existing condition is a health problem that existed before you apply for a health insurance policy.
A pre-existing condition can be something as common and as serious as heart disease, high blood pressure, cancer, type 2 diabetes, and asthma;
Inpatient: emergency hospitalization;
Outpatient: treatment received without emergency hospitalization;
High Cost Providers: expensive / private / international hospitals.

*Eligibility is based on health information provided and is subject to Bluestar AMG Approval.