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Top Up Health Insurance Form

In France, the healthcare system is known as "la Securité Sociale". In general, cares are taken in charge at 70% but what about the remaining 30% or any extra fees? This is where the top up insurance comes in!

We can offer you several solutions in regard to hospitalisation, general care, dental and optical to fit around your needs.

Please complete our form below for your free quotation:

How did you find our website?
 POLICYHOLDER DETAILS
Full Name:
 
Address in France:
 
Date of Birth:  
Occupation:  
Email Address:
 
Telephone:
 
Are you already insured in France?
If so, with which company?
 
     
Please indicate the following information on the people who you would like to insure also on the insurance policy. If you are more than 4, please contact us:
 PERSON 1
Full name:  
Date of Birth:  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
 PERSON 2
Full name:  
Date of Birth:  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
 PERSON 3
Full name:  
Date of Birth:  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
 PERSON 4
Full name:  
Date of Birth:  
Registered with CPAM, RAM-RSI or MSA?  
Social security number:  
     
 COVER
Hospitalization only (You will only be covered for hospitalization in your insurance package)  
Hospitalization  
General care (general or specialist consultations, X-Rays …)  
Dental / Orthodontist BASIC (You need cover for basic dental: cleaning, filling, general checkups …)  
Dental / Orthodontist MAX (on top of the basic cover, you need: dentures, crowns, bridges, implants …)  
Optical (You need cover for glasses, frames, contact lenses)  
Homeopathy  
Alternative Medicine (Chiropodist, Dietician, Acupuncturist, Osteopath, Chiropractor…)  
     
 
     
 
 
 
     
   
     
 
Exclusive Healthcare



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Tel: +33 (0)494 403 145

EMail: ceri.exclusive@gmail.com

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