Enrolment form

First Debit to

Plan selection

Health Cash Plan level:

Surgery Choices level:

Would you like to cover your partner?

Yes
No

Would you like to add cover for your partner? You’ll each have a separate policy and communications.

About you

Title *

First name *

Surname *

Gender *

Date of birth *

Must be between 16 and 65 years old

Phone *

Email *

Email

Confirm Email

About your partner

Your address

House name

House number

Address 1 *

Address 2 *

Address 3

Town *

Postcode *

County *

Direct Debit details

Please pay Westfield Health Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Westfield Health and if so, details will be passed electronically to my Bank or Building Society.

Banks and Building Societies may not accept Direct Debit Instructions for some types of account.

This is also the bank account into which we will pay your Westfield Health claims.

I am the account holder and no-one else is required to authorise the set up of this Direct Debit. *

Yes
No

The Direct Debit Guarantee

This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits
If there are any changes to the amount, date or frequency of your Direct Debit Westfield Health will notify you (normally 10 working days) in advance of your account being debited or as otherwise agreed. If you request Westfield Health to collect a payment, confirmation of the amount and date will be given to you at the time of the request
If an error is made in the payment of your Direct Debit, by Westfield Health or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society
If you receive a refund you are not entitled to, you must pay it back when Westfield Health asks you to
You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify Westfield Health

Marketing preferences

At Westfield Health, we help people to lead healthier lives and feel their best. We occasionally send out communications with ideas and information on health and wellbeing, plus special offers that we think are of value to you, invitations to take part in our research panel Westfield Insiders, and on the products we’ve designed to help keep you and your loved ones healthy and happy.

We’ll never make your data available to anyone outside Westfield Health for them to use for their own marketing purposes, we’ll treat your data with respect and will keep your details safe and secure.

Once your application is complete you can register for My Westfield and change your preferences at any time.

You can also change your marketing preferences by calling us on 0114 250 2000 or emailing us at [email protected].

We’d like to bring to your attention our Privacy Policy which details how your data is used and stored, and how to exercise your privacy rights.

Westfield Contributory Health Scheme Ltd (company number 303523), Westfield Health & Wellbeing Ltd (company number 9871093) are collectively referred to as Westfield Health and are registered in England & Wales.

Declaration *

By ticking this box, I confirm I have read and accepted the Terms and Conditions, Insurance Product Information Document and the Privacy Policy and that the information I have provided is complete and accurate.

You are responsible for the completeness and accuracy of the information that you have provided on this application form and that all of the persons that you have applied to cover are eligible for cover under the Terms and Conditions of this plan. To knowingly give false and/or misleading information will invalidate this insurance policy and may result in legal action being taken against you.