Application Form

Applying for healthcare with Foresters only takes a couple of minutes. If however you are applying for more than one individual, we ask that you download the form then email or return it to our offices.

Our details can be found on our contacts page.

Don’t want to fill in our online form? You can download and print your own copy of our application form using the button below.

Your Contact Details

Please enter your full name and email address below, before filling the application form below. If you are submitting this form on behalf of yourself and others, please be sure that you have obtained their consent first and that they have read and agree to our Data Protection Privacy Policy.

Your Name
Your Email Address

Section A - Applicants Details

Surname
Title
First / Middle Names
Date of Birth
Occupation
Guernsey Social Security number
Current health insurer (or previous if cancelled within 6 months)
Name & Practice of your registered doctor
How did you hear about us?
If joining an existing family or corporate group, please give details

Section B - Contact Details

Address Fields
Post Code
Contact Numbers
Home Number
Daytime / Mobile Number
Email Address

Section C - Cover

Please confirm the cover you wish to apply for.

Primary Care Scheme

Mandatory Cover - basic level of cover for doctors & nurses consultations, blood tests, consultations at the Emergency Department and essential or emergency ambulance conveyance. For more information please see our brochure.

Additional Benefits Scheme

Optional Add-on Scheme - Cover for other treatments such as minor operations, physiotherapy/osteopathy, allergy testing, ECGs and well person checks. For a full list of cover provided please see our brochure.

*A three month cover deferment applies for all schemes. This may be reduced or waived at the discretion of the Society.

Section D - Your Medical History

1) Are you currently in good health?

Do you have any ongoing medical conditions?

Please indicate the average number of times you have utilized the following Primary Care medical services in the past twelve months

Is the applicant pregnant?

Important - Applicant Declarations

Please read the following carefully before submitting the form

  1. To the best of my knowledge and belief, the information given within this form is true, complete and accurate. I understand that Foresters Healthcare can adjust premiums, end a person's policy or refuse payment of a claim in full or part should there be reasonable evidence that I have not taken reasonable care when providing any information requested in this application.
  2. Where this application provides information on behalf of any other person, I confirm that I have checked the information is correct prior to completing this application and that I have express agreement to submit this application on their behalf, or I am their legal representative.
  3. I consent to Foresters Healthcare seeking medical information from any doctor or medical practitioner who at any time has attended me concerning anything which affects my physical or mental health and i authorize the giving of such information. I further consent to Foresters Healthcare providing information to third parties such as my doctors surgery, Guernsey Revenue Service and States of Guernsey Health and Social Care, also any information sought by relevant authorities in the case of criminal investion.

Premiums are calculated based on an annual review and a standard rate is set for each year.

Foresters Healthcare reserves the right to charge a non-standard premium rate where applicants represent a non-standard risk based on their application and medical history. Foresters Healthcare also reserves the right to not accept any applicant that represents an unacceptable risk.

By signing this form you consent to the Society seeking medical information from any Doctor who at any time has attended you concerning anything which affects your physical or mental health and you authorise the giving of such information. Any costs incurred in the gaining of this information is not payable by the Society. You also consent to the Society providing information to third party companies such as your doctor’s surgery, Guernsey Social Services Department and the States of Guernsey Health and Social Care, also any information sought by relevant authorities in the case of a criminal investigation. Information and reports supplied by or to these parties are kept private and confidential and will only be provided to the applicant with prior permission from the party in question.

Data Protection

Due to the nature of Foresters Healthcare business and you wanting to engage with us, we have to ensure that you give us consent to process and hold your personal data. Ticking the following box confirms that you have read and agree to our Data Protection Privacy Policy. Checking the box below is evidence that you give your affirmative consent.

Section E - Payment Details

Indicate below how you would like to pay for your premium to Foresters Healthcare.

Payment Type

All direct debits are collected on the 27th of each month. Annual direct debits are collected in January.

Please note: We do not issue monthly accounts.

Section F - Other Information

Important - Submitters Declarations

Please read the following carefully

By submitting this form you agree that the data you have provided, both on behalf of other individuals and for yourself is accurate to the best of your ability.

Data Protection

Due to the nature of Foresters Healthcare business and you wanting to engage with us, we have to ensure that you give us consent to process and hold your personal data. Ticking the following box confirms that you have read and agree to our Data Protection Privacy Policy. Checking the box below is evidence that you give your affirmative consent.