Cochlear implant insurance



1

Implants

2

Personal

3

Payment

4

Declaration

This insurance is administered by Specialty Risks Limited whose registered office is at Aissela, 46 High Street, Esher, Surrey, England, KT10 9QY (registered number 6751834) and is authorised and regulated by the Financial Conduct Authority, firm reference number 771865.

Please take the time to read the information provided on the How we use your information page.


Your Cochlear Implant details

How many Cochlear Implants do you need to insure? *
One
Two

Do you wear one or two cochlear implants?

Title

First name

Last name

Address first line

Address second line

Town / City

County

Post Code

Daytime telephone

Email Address

Instruction to your Bank or Building Society to pay by Direct Debit

You are setting up a monthly Direct Debit for the value of £11.98


Service User Number:

6 9 8 9 4 0

Bank account holder

Bank account number

Sortcode

Please confirm  *

I am the only person authorised to setup direct debits on this account.

(Don’t worry if you are not the only person, just leave this unchecked and we will email you a form so you can still get this setup.)


Click here to view the Direct Debit guarantee

Please confirm  *

I would like to hear from you about new products in the future
You have understood and read the Insurance Product Information Document and Policy wording
You are a full time resident of the United Kingdom


Do you need any assistance?

0333 323 7950 (local rate call) • cochlear@specialty-risks.com

Monday to Friday 09.00 to 17.00