1General questions and details
2Your insurance
3Payment Information
  • Please note: You are about to purchase PharmaTax Insurance for £100.80 Your cover will not start until we have accepted this application. We reserve the right to refuse acceptance of any application for insurance. No liability is undertaken by us in connection with this proposal until cover has been issued with our authority.

    By completing this application, you consent to accept the Insurance Policy Terms & Conditions. A copy of the Policy Document is available on request. You also agree that you have read the Keyfacts and leaflet about our insurance services.

    Fields marked with an asterisk (*) are required.

    Data Protection Notice

    It is important that you understand how the personal information you give us will be used. Therefore, we strongly advise that you read our Privacy Statement, which you can find at Privacy Notice.
  • DD slash MM slash YYYY
  • Please enter a number from 1 to 1.
  • £ 0.00
  • Important Notes
    Before you complete the following declaration, please make sure that you have answered all the questions relating to the cover and not deliberately ignored information. It is essential that you disclose accurately all facts which influence acceptance of this application or terms to be applied. If you are not sure whether to include certain information, please do so anyway. If you do not tell us something relevant, your insurance may not be valid.

    I have read this proposal form and checked the answers given. As far as I know, the information on this form is accurate, true and complete. This proposal and declaration will be the basis of the Policy.