If you would like to become part of our network, please complete and submit the form below.

On completion of this form, please send a current pricelist and a copy of applicable licences to:
AXA Global Healthcare (UK) Limited, International House, Forest Road, Tunbridge Wells TN2 5FE, UK.
Fax +44 1892 503189 – Email GlobalNetworkmanagement.health@axa.com

Please make sure you complete all fields marked *.

Provider Information











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Key contacts

Insurance Manager

Finance Billing Manager

Guarantee of Payment contact

Provider bank details

Complimentary information

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Facility statistics

Hospital list of specialities and facilities

Yes No