You can apply for coverage online. However, if you prefer to complete the form offline, please use one of the PDFs below. If there isn't enough space for all your dependents, use an additional form. Once you've signed it, mail the form to Allianz at the provided address.
Direct Debit
If you choose to pay by Direct Debit, please complete and submit the appropriate Direct Debit Mandate as outlined below. Please note that quotes remain unchanged if you choose to pay by Direct Debit.
For payment in Euro, please complete the SEPA Direct Debit Mandate.
For payment in Sterling, please complete the GBP Direct Debit Mandate.
For payment in Swiss Franc, please complete the CHF Direct Debit Mandate.
Please save this form and use Adobe Reader (free) to electronically complete it
Dental questionnaire
If you are seeking dental cover and answered 'Yes' to any dental question in the health declaration section of the Application Form, please complete and return this questionnaire.