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  • NEWS
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  • PRODUCTS
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    • Primary Care
  • PARTNERS
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Employer Application FormKirstyKF2020-07-23T16:37:40+02:00

Step 1 of 6

16%
  • Employer Details

  • Company Contact Details

  • Premium Collection Details

  • Please enter a number from 1 to 7.
  • Contact Person and Billing Details for Pay Point 1

  • Monthly billing statements, reconciliations and premium notices will be sent to the above email address.
  • Contact Person and Billing Details for Pay Point 2

  • Monthly billing statements, reconciliations and premium notices will be sent to the above email address.
  • Contact Person and Billing Details for Pay Point 3

  • Monthly billing statements, reconciliations and premium notices will be sent to the above email address.
  • Contact Person and Billing Details for Pay Point 4

  • Monthly billing statements, reconciliations and premium notices will be sent to the above email address.
  • Contact Person and Billing Details for Pay Point 5

  • Monthly billing statements, reconciliations and premium notices will be sent to the above email address.
  • Contact Person and Billing Details for Pay Point 6

  • Monthly billing statements, reconciliations and premium notices will be sent to the above email address.
  • Contact Person and Billing Details for Pay Point 7

  • Monthly billing statements, reconciliations and premium notices will be sent to the above email address.
  • Payment & Participation Details

  • DD dash MM dash YYYY

  • Notes : Should any pay points have elected for their employees to pay via individual debit order an application form will be required to be completed by each participating employee providing the necessary consent to Cinagi to collect their premiums.
    The billing details of all new applications will be sent to the billing e-mail address as and when the applications are completed
  • Intermediary Details

  • Employer Warranty



  • -that by completing and submitting this form I am authorised by the employer to enter into this agreement and establish a group scheme for the employer.
    -that the employer will facilitate the deduction of premiums from employees, where applicable,and pay these across to Cinagi by the 1st working day of each month.
    -that the member participation and payment terms and conditions outlined above are accurate.
    -that the employer will provide Cinagi with updated staff details each month (where applicable).
    -that the appointed intermediary may assist Cinagi with updating membership & billing information if required.

  • MM slash DD slash YYYY

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Underwritten by Infiniti Insurance Ltd, a licensed Non-Life Insurer and authorised financial services provider (FSP 35914)
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