You’re nearly there… Just a few more steps and you’ll be setup. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4Title *--- Select Choice ---Mr.Mrs.MissMsDrProfMxLadyLordRevRgt.HonName *FirstLastDate of birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Mobile number *NextAddress *Address Line 1Address Line 2CityState / Province / RegionPostal CodeNextGetting your Direct Debit setup Authorise your Direct Debit payment. Account holder name *Sort code *Account number *Building society roll number (if you have one)You can find it on your card, statement or passbook The Direct Debit Guarantee The Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits If there are any changes to the amount, date or frequency of your Direct Debit the organisation will notify you (normally 10 working days) in advance of your account being debited or as otherwise agreed. If you request the organisation to collect a payment, confirmation of the amount and date will be given to you at the time of the request If an error is made in the payment of your Direct Debit, by the organisation or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society If you receive a refund you are not entitled to, you must pay it back when the organisation asks you to You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify the organisation. Confirmation *I've reviewed the policy documents and IPID, and I'm ready to start my 12-month agreement with BHSFMarketing preferencesEmail meText mePhone meWe'd like to keep you up to date with products and services that we think help our customer's health and wellbeing. If you'd like us to send this to you, please let us know how you'd like us to contact you, you can select as many options as you like. You can change your mind at any time by visiting your customer portal, by emailing us enquiries@bhsf.co.uk or calling 0121 454 3601. If you prefer we don't contact you for marketing purposes please don't select any of the options.NextReview and proceed This is a final preview of your submission. Please take a moment to verify your information. You can also go back to make changes. Plan Level 5: £37.99 per month (12-month period) Annual premium total: £455.88 Which includes IPT (Insurance Premium Tax): £54.71 Cover (annual benefits): £150 for dental £500 for dental trauma £150 for optical £300 for therapies (combined maximum benefit) including physiotherapy, osteopathy, chiropractic, acupuncture, homeopathy and reflexology £150 for chiropody and podiatry £500 for diagnostic consultations (including scans and tests) £30 for NHS or private prescriptions GP Helpline and Private Prescription Service Confidential Support Helpline Online Physiotherapy Assessment and Support Online Dental Screening Online Optical Screening Skin Cancer and Melanoma Screening App Gym discounts Perks discount portal Updating preview… number one) column PreviousSubmit h Policy details Review the policy details here Product information document Review the Insurance Product Information Document (IPID)