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
Are you a permanent resident of Guernsey?
First / Middle Names
Date of Birth
Occupation
Guernsey Social Security number
Current health insurer
Name/Practice of your registered doctor
Introduced by (if a personal recommendation)
Join to existing member or group (if applicable)

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?

On average, how many times do you utilise the following healthcare services per calendar year:

Is the applicant pregnant?

Important - Applicant Declarations

Please read the following carefully

The questions in this application must be answered fully and accurately to the best of your knowledge. You must disclose any material facts or circumstances that would influence the assessment and acceptance of your application. Failure to do so may cause the insurance to be declared void. Premiums are based on an annual review and a standard rate is set for each year.

The society reserves the right to charge a non-standard premium rate where applicants have pre-existing medical conditions to represent a non-standard risk based on their medical history.

The society also reserves the right to not accept into membership any applicant that represents an unacceptable risk. Should payments not be received by renewal dates, medical cover will be suspended until such payment is received.

By checking the following boxes you consent to the Society seeking further information to support your application from any Doctor who has at any time attended you concerning anything which affects your physical or mental health, and you also authorise the giving of such information.

Any costs of incurring this information is not payable by the Society. You also consent to the Society providing information to your doctor's surgery, Guernsey Social Services Department, States of Guernsey Health and Social care and any information sought by relevant authorities in the case of a criminal investigation. Information and reports supplied by or to those 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.