All fields are required unless labelled optional.
Your Name
Please complete this field
Your company's name
Please complete this field
Your company's Simplyhealth intermediary reference
Please complete this field
Which companies do you need to have access to view?
Please complete this field
Email address
Please ensure you provide a work email address and not a generic shared email address.
Please provide a valid email address
Contact number>
+44
Please complete this field
Job title
Please complete this field
What should you have access to view on the portal?
Invoice only
Admin only
Full access (invoice and admin)
Comments (optional)
Submit