Which Vitality product are you interested?Which Vitality product are you interested? Who is the cover for? About YouTitleDate of BirthDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderSmoke StatusName* First Last Email* Enter Email Confirm Email Phone*Postcode* About Your PartnerTitleName First Last Date of BirthDD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920GenderSmoke Status Cover type do you need? Annual Salary*Mortgage Balance*Cover Amount*Mortgage Term*Please select5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 years21 years22 years23 years24 years25 years26 years27 years28 years29 years30 yearsMy entire lifeCover Term*Please select5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 years21 years22 years23 years24 years25 years26 years27 years28 years29 years30 yearsMy entire lifeDo you have children?About Your ChildrenChild Information Title Name Date of Birth Gender Smoker Status Email Phone Edit Delete There are no Children. Add Child Please tick which Vitality rewards you are most likely to benefit from? Select All Get cash back incentives yearly Apple Watch Series 7 Offer Amazon Prime Offer Up to 40% off Polar, Garmin or Withings devices Up to 36% off a range of Fitbit devices Get 30% off selected Samsung Galaxy Watches Up to 50% off a pair of running shoes Up to 50% off monthly memberships at Nuffield Health, PureGym gyms or Virgin Active gyms Earn up to 40% cashback on Peloton hardware Weight Watchers Up to 75% off Champneys Health Spas Earn free cinema tickets Earn free Caffe Nero coffees Rakuten TV offer 25% discount with Mr & Mrs Smith Please tick which Vitality rewards you are most likely to benefit from? Select All Get cash back incentives yearly Apple Watch Series 7 Offer Amazon Prime Offer Up to 40% off Polar, Garmin or Withings devices Up to 36% off a range of Fitbit devices Get 30% off selected Samsung Galaxy Watches Up to 50% off a pair of running shoes Earn up to 40% cashback on Peloton hardware Weight Watchers Up to 75% off Champneys Health Spas Rakuten TV offer 25% discount with Mr & Mrs Smith We will automatically generate a quote for you using the personal and medical information you have provided. By clicking "Get my quote" you agree that we will call you to discuss your quote. If you would also like to know about other Vitality Corporate Services Limited products or services that we believe will be of interest to you, please select the ways we can contact you below. You can read our full Privacy Policy at health-rewards.co.uk/privacy. You can also request a copy from us. This iframe contains the logic required to handle Ajax powered Gravity Forms.