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Become a Member

Application Form

Apply for new membership

Change current details

Effective date:

dd/mm/yy

Previous Health Fund Details

Fund Name:

Member:

Date paid to:

dd/mm/yy

Cover Code:

Eligibility

Ex Member/Dependant:

Member No.:

Ex/Current worker in the forestry, timber, paper industries:

Employer:

Ex/Current contractor to the forestry, timber, paper industries:

Employer:

Contracted to Company:

Dependant of the above (If you tick this box you must provide details in one of the other eligibility criteria)

Choice of cover

Family:

Couple:

Single:

Combined Packages

Premier Package:

Excess:

Essential Package:

Excess:

Hospital Cover

Premier:

Excess:

Public:

Ancillary / Extras Cover

Premier extras:

Select extras (Singles Only):

Title:

Surname:

Given Names:

Sex:

Male:

Female:

Date of Birth:

dd/mm/yy

Postal Address

Street / PO Box:

City / Suburb

State:

Post Code:

Home Address

Street:

City / Suburb

State:

Post Code:

Home phone:

Work / Day phone:

Mobile:

Fax:

Email

Persons to be covered

Surname

Given Names

Sex

D.O.B

Relationship
to member

Existing
conditions

Male:

Female:

dd/mm/yy

Male:

Female:

dd/mm/yy

Male:

Female:

dd/mm/yy

Male:

Female:

dd/mm/yy

Male:

Female:

dd/mm/yy

Male:

Female:

dd/mm/yy

If a dependant is 18 or over an adult dependant/student dependant declaration is required.

Are you aware of any treatment or hospitalisation needs in respect of any person to be covered by this membership?

Yes:

No:

Please detail any conditions or ailments the signs of which existed at any time in the past 6 months.

Declaration
I hereby declare the above statements to be true and complete and agree to abide by health benefit fund rules of Health Care Insurance Ltd as amended from time to time.

I acknowledge that this application form and brochure does not contain all the Rules of Health Care Insurance Ltd, but I am free to inspect the full copy of the Rules at the office of Health Care Insurance Ltd.
I also acknowledge my membership is subject to the pre-existing Rule, waiting periods and eligibility criteria as explained in this brochure.

I acknowledge that Health Care Insurance Ltd has a Privacy Policy which I may view upon request, and I will inform any dependants referred to on this application of the existence of the Health Care Insurance Ltd Privacy Policy.

I consent to the collection, use and disclosure of my personal and sensitive information in the provision by Health Care Insurance Ltd of a health insurance service and I have authority to provide and consent to the release of personal and sensitive information on behalf of the dependants referred to in this application.
I authorise the release of personal and sensitive information from my previous health fund, and from any hospital, medical practitoner or other health service provider that Health Care Insurance Ltd deems necessary to administer my policy.

If the information supplied on this application is inaccurate or fraudulent, I acknowledge Health Care Insurance Ltd may refuse to pay a claim, cancel the policy or require payment of any additional premium loading payable in accordance with the Lifetime Health Cover legislation.

Agree:

Disagree:

Date:

dd/mm/yy

Payment

Title:

Surname:

Given Names:

Sex:

Male:

Female:

Date of Birth:

dd/mm/yy

Postal Address

Street / PO Box:

City / Suburb

State:

Post Code:

Member Number:

Invoice

Frequency

Monthly:

Quarterly:

Annually:

		Application form

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Disclaimer
This web site is based on available information sourced from HCI members and management. While every effort is made to ensure the information is current and accurate, HCI takes no responsibility for any errors or omissions. Site visitors should confirm all information with the relevant organisation listed before acting on such information.