Breast surgery insurance

About us

About this insurance

Please complete the below form and submit it to us for immediate cover.

Alternatively, You can download the form as a PDF. Or you can download the form as a Word document.

If you have any difficulty in completing this application form or downloading please do not hesitate to call us on: 0845 685 2610 or write to us at:

Trafalgar Risk Management
The Lloyds Building
12 Leadenhall Street
London, EC3V 1LP

It is understood that by completing and submitting your order, along with paying the premium, you wish to proceed with cover.

Insured Details
Name *
Address *
Postcode *
Telephone number: *
Email address *
Date of birth *
Surgeon/Consultant's Details
Surgeon/Consultant's Name: *
Surgeon/Consultant's Address *
Postcode *
Qualifications *
Hospital/Clinic *
Hospital/Clinic Address: *
Postcode *
Date of Surgery (if known):
Make of implant: *
Type of implant: *
Schedule
Policy Type: Breast Assured Insurer: Templeton Insurance Limited, Isle of Man Period of Insurance: 60 hours from initial surgery for a period of 12 month Limits of Indemnity: £5,000 Excess: £250 each & every claim Premium: £500 Exclusions & Conditions: As per policy wording
Declaration
I understand that the underwriters will etermine their terms and onditions pon the information provided in connection ith this pplication and the fact that this pplication is unsigned will not rejudice underwriters rights as determined bove.
Agree/Disagree *	I agree I disagree
All enquiries will be dealt with in the strictest confidence. In view of the confidential nature of the insurance, please advise us on how you would like us to contact you and whether you require the documents to be sent to you in the post. We can hold them in our office and notify/confirm cover is in place by email if this would be more preferential to you.

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