Postal Address
PO Box 484 Darlinghurst
NSW 1300 Australia
Ph +61 2 9211 7780
Fax +61 2 9211 7790
Personal Details
Title:
Mr
Mrs
Ms
Miss
Dr
Prof
First Name
Last Name
Date of Birth
Sex
Male
Female
Marital Status
Married
Single
De-Facto
Couple
Sole Parent
Postal Address
Suburb
State
Post Code
Home Phone
Work Phone
Mobile
Country
Email
» Persons to be covered (excluding applicant)
Husband/Wife/Partner
Sex
Male
Female
Date of Birth
Child 1
Male
Female
Age
Child 2
Male
Female
Age
Child 3
Male
Female
Age
Child 4
Male
Female
Age
Child 5
Male
Female
Age
Residency/ Visa Details
I/We will be living in Australia for the following reason:
Temporary work transfer
Indefinite work transfer
Working Holiday
Migrating back to Australia-previously an Australian resident
My/Our due date of arrival in Australia is:
I/We will be eligible for Medicare Benefits:
Yes
No
Not Sure
I/We will be on a Visitors permit in Australia:
Yes
No
I/We will be on a Visa class 457:
Yes
No
Other Visa Class
Do You Have Private Health Fund?
Hospital
Extras/Ancillary
Ambulance Only
Does your partner have Private Health Fund?
Hospital
Extras/Ancillary
Ambulance Only
Health Cover Requirements
» Hospital Cover Options
I/We require the following level of Hospital Cover:
Private and Public Hospital Cover
(Covers you both in Public & Private Hospitals as a Private Patient)
I/We are willing to pay a Hospital Excess of:
Nil
$100 - $200
$200 - $500
$500 - $1,000
I/We require our hospital policy to cover the following services:
Obstetrics/Pregnancy
IVF/GIFT (fertility programs for women)
Open Heart Surgery
Hip and/or Knee Replacement
Cataract / Glaucoma Surgery
Cosmetic Surgery
Psychiatric Conditions
» Ancillary / Extras Cover Options
I / We would like to be covered for the following services: (please tick all services required )
The following services are `Low Cost Services' and will not increase your premiums / membership fees excessively.
Optical
General Dental
Chiropractic
Osteopathy
Physiotherapy
Acupuncture
Naturopathy
Homeopathy
Remedial Massage
Gym Membership
Sporting Goods
Pharmaceutical
Dietetics
Podiatry
The following services are `High Cost Services' and will increase your premiums / membership fees accordingly.
Major Dental
Orthodontics
Hearing Aids
Home Nursing
Speech Therapy
Occupational Therapy
Blood Glucose Monitor
The following services are not covered by all health funds however please select the following services you require cover for.
Vitamins and Health Supplements
Herbalism
Reflexology
Iridology
Kinesiology
Myotherapy
Aromatherapy
Psychology
Audiology
Additional Information