Healthcare Enquiry Form

Stackhouse Poland specialise in providing Private Medical insurance solutions, for Individuals for their requirements both domestically and internationally and for Businesses large or small. The protection of your personal health or for the well being of your staff is important and Stackhouse Poland can tailor a policy to suit your requirements whether simple or complex.

Please complete the brief form below and we will contact you to assist with your enquiry

*Title: *Name: *Last Name: Company Name (if applicable):

Address *Line One: Line Two: *Town: Region: *Postcode:

*E-mail (Please confirm you are happy for us to correspond with you by e-mail): *Telephone Number: Fax Number:

*Is this enquiry for:

Please note that completion of this form does not commit you to any form of cover. This would only happen once we have assessed your demands and needs and quoted premiums and terms to you.

By submitting your details, you agree to the use of your personal information as set out in our privacy policy and terms of business. This includes for the purposes of administering our web site services and for fraud prevention. Your details will also be added to our mailing list if you indicate such by ticking the box below.

We do not supply your details to any third parties unless you specifically ask us to.

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