If you would like to become part of AXA PPP International's provider network, please complete and submit the form below.

On completion of this form, please send a current pricelist to:
AXA PPP International, International House, Forest Road, Tunbridge Wells TN2 5FE
Fax +44 1892 503189 – Email GlobalNetworkmanagement.health@axa-ppp.co.uk

Please make sure you complete all fields marked *.

Provider Information

Yes No

Key contacts

Insurance Manager

Finance Billing Manager

Guarantee of Payment contact

Provider bank details

Complimentary information

Yes No

Facility statistics

Hospital list of specialities and facilities

Yes No