ACC5903 Application Form FSR

8/9/2019 ACC5903 Application Form FSR

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Company/Association

Date employed

Membership number

$2,000

$4,000

Title Mr Mrs Miss Ms Other Date of birthdd mm yySurnameFirst name(s) Male FemaleHeight and weight cm kg Have you smoked in the last 12 months? Yes NoResidential addressTown/City PostcodePostal address(if different to residential)Town/City PostcodeTelephone numbers Home Business MobileEmail Home Business

OccupationName of your usual GPand practiceGPs fax number

Name of your usual dentist

Dentists fax number

and practice

For office use only Agent/Broker name and number New membership number


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2 2Plan details Which plan are you applying for?

Please select one

SmartCare Hospital and Surgical base plan

SmartCare+ Hospital and Surgical base plan

Please select your excess

$0

$250

$500

$1,000

$2,000

$4,000

Once you have selectedyour base plan, you can add

Specialist plan

Natural Health plan

GP plan

Dental and Optical planany or all of these plansSelect if you are not upgrading the plans subsidised by your employer

Group only

(complete section 2 if adding non-subsidised options)

Please select one

StaffCare Essential Care base plan

StaffCare+ Essential Care base plan



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$0

$250

$500

$1,000

Once you have selectedyour base plan, you can add

Specialist Care

Everyday Careany or all of these plans


$0

$250

for Specialist Care only(Note: Everyday Care has no excess)

Select if you are not upgrading the plans subsidised by your employer

Group only

(complete section 2 if adding non-subsidised options)

SmartStay Hospital and Surgical base plan (this plan is for non-residents who hold a work visa)Please select your excess $0 $250 $500 $1,000 $2,000 $4,000Once you have selectedthe base plan, you can SmartStay+ (Specialist)add this plan

3Details of spouse/partner

If not taking the sameplan(s) as the main

member, please specify

Title

Other Date of birthdd mm yySurname


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First name(s)

Mr

Mrs

Miss

Ms

Male

FemaleHeight and weight cm kg Have you smoked in the last 12 months?

Yes

NoName of your usual GP

GPs fax number

and practice


Dentists fax numberand practice

4Details of other participants Participants include dependants/whangai and parents

To be included under the plan(s), your child(ren) must be under 25 years of age.

If not taking the same plan(s) as the main member, please specifyChild 1 surnameFirst name(s)

Male

FemaleHeight and weight cm kg Date of birth

(if over 10 years of age) dd mm yy

Name of your usual GP

GPs fax number

and practice


Dentists fax number


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and practice


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To be included under the plan(s), your child(ren) must be under 25 years of age.

If not taking the same plan(s) as the main member, please specify

Child 2 surnameFirst name(s)

Male

Female

Height and weight cm kg Date of birth

(if over 10 years of age) dd mm yy


GPs fax number

and practice


Dentists fax number

and practice

To be included under the plan(s), your child(ren) must be under 25 years of age.If not taking the same plan(s) as the main member, please specifyChild 3 surnameFirst name(s)

Male


(if over 10 years of age) dd mm yyName of your usual GP

GPs fax number

and practice


Dentists fax number

and practice

Parent (of either the main member or spouse/partner)If not taking the same plan(s) as the main member, please specify


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Parent 1 surnameFirst name(s)

Male


dd mm yyOccupation Have you smoked in the last 12 months?

Yes

No


GPs fax number

and practice


Dentists fax number

and practice

If not taking the same plan(s) as the main member, please specifyParent (of either the main member or spouse/partner)Parent 2 surnameFirst name(s) Male Female

Height and weight cm kg Date of birth

dd mm yy

Yes

No

Occupation Have you smoked in the last 12 months?


GPs fax number

and practice


Dentists fax number

and practice


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5 5Commencement date

If you have a preferred commencement date for your policy/additional plan/additional participant, pleaseadvise us. Otherwise, the commencement date will be the date on your MembershipCertificate issued by us.

dd mm yy

6Health declaration

Pre-existing conditions are not covered unless they have been declared by you inthis health declaration section and specificallyaccepted by Accuro Health Insurance. Conditions arising between signing the application form and the cover commencement date willequally be deemed to be pre-existing. Therefore, it is important that you adviseus of any changes to the information provided betweensubmission of this application and acceptance by us.

You are hereby obliged on request to provide any further information that we might require.

Only pre-existing conditions that have been declared on the application form andspecifically accepted by Accuro Health Insurancewill be covered.

Please indicate below if any of the lives to be insured have ever:

experienced, or are currently experiencing; orhad symptoms of, or are currently experiencing symptoms of; orbeen treated for, or are currently being treated for; orbeen advised to seek testing, therapy, consultation or treatment for any of thefollowing:If you answer YES to any question below, please complete the indicated questionn

aire in section 7.

Please leave no question unchecked

6.1 High blood pressure, hypertension or any abnormal blood pressure readings (refer to 7.1)Yes

No

6.2 Abnormal lipids or cholesterol tests (refer to 7.2)

Yes

No

Blood disease or disorder, haemochromatosis, anaemia, leukaemia, haemophilia, vitamin B12 deficiency

Yes


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No

or abnormal blood count (refer to 7.0)

6.4 Varicose veins, deep vein thrombosis and/or blood clots (refer to 7.0)Yes

No

6.5 Skin disease or disorder, dermatitis, psoriasis, rosacea, acne or eczema (refer to 7.0)Yes

No

6.6 Skin lesion, cyst, ganglion cyst, suspicious mole, melanoma or other skin cancer (refer to 7.3) Yes No6.7 Asthma, lung disorder, bronchitis, emphysema, TB, chronic obstructive airways disease, pneumoniaor any other respiratory or breathing disorder (refer to 7.4)

Yes No6.8 Gastrointestinal disease or disorder, colitis, Crohns disease, gastritis, bowel polyps, ulcers, reflux or anyother disease or disorder of the digestive system (refer to 7.6)Yes No

6.9 Hernia (refer to 7.0)Yes

No

6.10 Haemorrhoids, anal bleeding, anal fissures or pilonidal sinus (refer to 7.0

)Yes

No

6.11 Back and/or neck disease or disorder, ankylosing spondylitis, scoliosis, whiplash or sciatica (refer to 7.5) Yes No6.12 Joint disease, disorder or injury including knees, ankles, feet, toes, hips, shoulders, arms, elbows, wrists,hands or fingers (refer to 7.5)Yes No6.13 Muscle, ligament and/or tendon disease or disorder, tendonitis, bursitis, O

OS, RSI or carpal tunnel(refer to 7.5)Yes No

6.14 Arthritis, rheumatism or gout (refer to 7.0)Yes

No


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6.15 Chronic fatigue, fibromyalgia or chronic pain syndrome (refer to 7.0)Yes

No


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Neurological disease or disorder, stroke, transient ischaemic attack (TIA), multiple sclerosis, paralysis,

Yes

No

migraines, meningitis or motor neuron disease (refer to 7.0)

6.17 Epilepsy and/or seizures (refer to 7.0)Yes

No

6.18 Vertigo, recurrent dizziness or fainting episodes (refer to 7.0)Yes

No

6.19 Breast disease or disorder, breast lumps, breast cysts or breast pain (refer to 7.0)Yes

No

6.20 Gynaecological disorder of any kind, endometriosis or polycystic ovarian syndrome (refer to 7.0)Yes

No

6.21 Cancer or tumour whether malignant or benign (refer to 7.3)Yes

No

6.22 Chest pain or angina (refer to 7.7)Yes

No

6.23 Heart attack, heart failure or heart surgery (refer to 7.7)Yes

No

6.24 Heart murmur, heart defect, rheumatic fever or any other heart disorder (refer to 7.7)Yes


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No

6.25 Diabetes, insulin resistance, abnormal blood sugar or glucose tolerance tests (refer to 7.8)Yes

No

6.26 Disease or disorder of the pancreas or gall bladder (refer to 7.8)Yes

No

6.27 Gland disease or disorder of the thymus, adrenal or pituitary glands, testes and/or ovaries (refer to 7.0)Yes

No

6.28 Thyroid disease or disorder or abnormal thyroid function tests (refer to 7.

0)Yes

No

6.29 Ear disease or disorder or hearing loss (refer to 7.0) Yes No6.30 Eye disease or disorder, blindness, glaucoma, cataracts, macular degeneration and/or visual defects(refer to 7.0)Yes No6.31 Nasal disorders, allergies, sinusitis, hay fever, recent and/or recurrent sinus infections or nasal blockages

(refer to 7.0)Yes No

6.32 Throat disease or disorder (refer to 7.0) Yes No6.33 Autoimmune disease or disorder including coeliac disease, Gravesdisease orsystemic lupus erythematosis(refer to 7.0)Yes No6.34 Kidney disease or disorder, kidney stones or kidney infections, bladder disease or disorder, incontinence,urinary difficulties, recent and/or recurrent urinary tract infections or any other urinary condition (refer to 7.0)Yes No

6.35 Liver disease or disorder, hepatitis, fatty liver or abnormal liver function tests (refer to 7.0)Yes

No

6.36 Prostate disease or disorder or abnormal prostate tests (refer to 7.0)Yes


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No

6.37 Tooth and/or gum disease or disorder (refer to 7.0)Yes

No

6.38 Oral surgery, wisdom teeth, impacted or unerupted teeth or cysts, within the last 12 months (refer to 7.0)Yes

No

6.39 Any history of recurrent ear infections, tonsillitis and/or adenoid complaints (refer to 7.0)Yes

No

6.40 Any current or recent ear infections, tonsillitis or adenoid complaints (refer to 7.0)Yes

No

6.41 Operation for grommets or advised one may be needed (refer to 7.0)Yes

No

Any other illness, accident, injury, condition, complaint, disability, medication or disorder not already

Yes

No

stated (refer to 7.0)

Please note these definitions apply wherever mentioned:

Recurrent more than once in any 12-month periodRecent within the past 12 months


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Have any of the lives to be insured been hospitalised or had any tests, medicaltreatment or investigations in thelast five years for any condition not already stated, including, but not limitedto, blood and/or urine test, X-ray,ultrasound, CT scan, mammogram, MRI, gastroscopy, colonoscopy, endoscopy, hysteroscopy and laparoscopy?If YES, please provide details in 7.0.Yes NoIn the past five years, have any of the lives to be insured had more than five consecutive days off work or schooldue to any condition not already stated? If YES, please provide details, including date(s) and reason(s).Yes No

Life assured nameDetails

Please include date(s) and reason(s)

Have any of your parents, brothers, sisters or children (living or dead) had orbeen diagnosed with any of thefollowing: cancer, stroke, heart disease, diabetes, kidney disease, Huntingtons chorea, muscular dystrophy,

Yes

No

cystic fibrosis, familial polyposis, polycystic kidney disease, multiple sclerosis, inherited neurological orblood disease or any familial and/or congenital disease or disorder? If YES, please complete the following.

Life assured name

Medical conditionFamily member affectedIf cancer, specify type and siteAge(s) at diagnosisCurrent age(s)Age(s) at death

To be completed by males only

Have you ever experienced any signs or sympoms of, or are you currently receiving or have you everreceived counselling, investigations or treatment from a health professional for, any of the following:

Blood in the urine, slow urinary stream, problems with passing urine, disease ordisorder of the testicles,

Yes

No


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bladder or urethra or sexual dysfunction. If YES, please provide details in 7.0.

To be completed by females only

Have you ever experienced any signs or sympoms of, or are you currently receiving or have you everreceived counselling, investigations or treatment from a health professional for, any of the following:

Irregular, heavy or painful menstrual bleeding, ovarian or hormonal problems, complications of pregnancy,

Yes

No

abnormal smear(s) or painful intercourse. If YES, please provide details in 7.0.

If you ticked no to all questions, please proceed to section 8


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If theres not enough space on this form, please provide your details on a separate sheet

7.0General medical questionnaire

Question number

Please describe your medical condition

Please provide the date when youfirst experienced symptomsdd mm yy

Please describe the symptoms

Are these symptoms

Yes

No

When did you last experience any symptoms?

completely resolved?

dd mm yy

How frequent and severe are the occurrencesor attacks of the condition? per month/per year (delete one)

Mild

Moderate

Severe

Have you been referred to a specialist or had any

If YES, please provide details below. What type of investigations, treatment

Yes

No

and/or medication are you currently taking (dosage and amount)?

investigations and/or treatment?

Has the treatment changed during


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If YES, please provide details. If theres not enough space on the form,

Yes

No

please provide your details on a separate sheet.

the last 18 months?

Question number




Are these symptoms

Yes

No



dd mm yy

How frequent and severe are the occurrences

or attacks of the condition? per month/per year (delete one)

Mild

Moderate

Severe



Yes

No




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Yes

No


the last 18 months?


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Question number




Are these symptoms

Yes

No



dd mm yy


Mild

Moderate

Severe



Yes

No





Yes

No


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the last 18 months?

Question number




Are these symptoms

Yes

No



dd mm yy


Mild

Moderate

Severe



Yes

No





Yes


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No


the last 18 months?


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Question number




Are these symptoms

Yes

No



dd mm yy


Mild

Moderate

Severe



Yes

No





Yes

No


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the last 18 months?

Question number




Are these symptoms

Yes

No



dd mm yy


Mild

Moderate

Severe



Yes

No





Yes


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No


the last 18 months?


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7.1 7.1Blood pressure questionnaire

When did you first become aware you had highblood pressure?dd mm yy

What medication or treatment are youcurrently taking (or supposed to be taking) forblood pressure?

Has your treatment changed in

Yes

No If YES, please provide details.

the past 12 months?

How often is your blood pressure

checked and by whom?

What were your three most recent 1mm

yy

blood pressure readings? ddPlease include the dates that the readings were obtained

2

dd

mm

yy

3

dd mm yyHave you ever been admitted to hospital or

If YES, please provide dates, outcome of consultation(s) and details regarding

consulted a specialist or been referred to a

Yes

No

any investigations and/or treatment.


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specialist as a result of your blood pressure?

Do you suffer from any complications

Yes


or associated conditions?

7.2Cholesterol questionnaire

When did you first become aware you had

abnormal cholesterol?dd mm yy

What medication or treatment are youcurrently taking (or supposed to be taking)for abnormal cholesterol?

Has your treatment changed in the

Yes


past 12 months?

How often is your cholesterolchecked and by whom?

What were your three most recent 1cholesterol results?

dd

mm

yy

Please include the dates that the readings were obtained

2

dd

mm

yy

3


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dd mm yy

Have you ever been admitted to hospital,

If YES, please provide dates, outcome of consultation(s) and details regarding any

Yes

No

consulted a specialist or been referred to a

investigations and/or treatment.specialist as a result of your cholesterol?

Do you suffer from any complications

Yes


or associated condition(s)?


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Pre-malignant

Benign

Unsure

Have you received any treatmentin the past three years?

Yes


Has there been any recurrence?

Yes


Have you seen a specialist, do you require anyon-going follow-up or treatment or has any

Yes

No If YES, please provide details.follow up/further treatment been recommended?

7.4

Respiratory disorders questionnaire

Please give details of the type of breathingdisorder e.g. asthma/bronchitis/otherWhen did you last experience symptoms?What treatment and/or medication have youbeen prescribed?dd mm yyHow frequent are the symptoms? per month/per year (delete one)Have you been hospitalised and/or beenon a nebuliser in the last two years? Yes No If YES, please provide the cause and date.

dd mm yy

Have you been prescribed steroids

Yes



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(e.g. prednisone) in the last two years?Have you been referred to a specialist for

Yes



Do you consider your breathing disorder to be

Mild

Moderate

Severe


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7.5 7.5Musculoskeletal questionnaire

What is the type of condition/disorderand what body part is affected?Please indicate if left or right limb.

When did you first suffer from this condition/complaint/injury, and how did it occur?How long did the symptoms last?When did you last suffer from symptoms?

Has this condition occurred more than once?

Yes


Have you been referred to a specialist for

Yes



Have you had any investigations?

Yes

No If YES, please provide details of type, date and results.

Have you had any treatment (including surgery)?

Yes

No If YES, please provide details including date.

Have you had any time off work as a

Yes

No If YES, please provide details and duration.

result of this condition?

Are you currently receiving treatment?


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Yes


Are you awaiting investigations, treatmentor surgery or have you been advised that

Yes

No If YES, please provide details.treatment or surgery will be required?


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7.6 7.6Gastrointestinal tract questionnaire

Do you suffer from or have you been advised

Indigestion

Ulcer

Gastritis

Crohns disease

by a medical practitioner that you suffer from

Ulcerative colitis

Heartburn

Hiatus hernia

Gastro-oesophageal reflux disease (GORD)

Irritable bowel syndrome

Other, please specify

When did you first experience

symptoms of this condition?

dd

mm

yy

When did you first seek an

opinion regarding this condition?dd mm yy

Have you ever undergone or beenadvised to undergo any investigations ofthe gastrointestinal tract?(e.g. gastroscopy, endoscopy, colonoscopy, other?)Have you been referred to or consulted aspecialist about symptoms of any of the above? Yes No If YES, please provide details.Yes No If YES, please provide details.Have you undergone or been advised toundergo any treatment (including surgery)? Yes No If YES, please provide details


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including date(s) and outcome.Do you still experiencesymptoms of this condition? Yes No If No, when did you last experience symptoms?If YES, how many times per year?

Have you in the past or are you currently

Yes


taking any medication for this condition?

7.7Cardiac questionnaire

Do you suffer or have you been advised by a

Chest pain

Angina

Heart attack

medical practitioner that you suffer from

Heart failure

Heart murmur

Heart defects

Rheumatic fever

Other, please specify

When did you first experience

symptoms of this condition?dd

mm

yy

When did you first seek an

opinion regarding this condition?dd mm yy

Have you been referred to or consulted a


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Yes


specialist about symptoms of any of the above?

Have you ever undergone or been advised to

Yes


undergo any investigations and/or treatmentfor this condition?


Are there any residual effects?

Yes

Do you require any on-going

If YES, please provide details including

Yes

No

treatment undertaken and/or medication prescribed.

treatment and/or medication?


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7.8 7.8Diabetes or related issues questionnaire

Please describe your medical conditionWhen were you diagnosed with the

dd mm yy

above condition?Have you been referred to a specialist or

Yes


had any investigations and/or treatment?

Please provide the dates and results of 1

mm

yy

your last three blood sugar tests dd

2

dd

mm

yy

3

dd mm yy

What regular medication are you currently taking?

Please provide details of each drug and dose taken

Has your medication changed during

Yes


the past five years?

Yes


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Have you ever had any complications of thiscondition (including but not limited to diabetic coma, insulinshock, kidney disease, any amputations)?

8Premiums Which method would you like to use for payment of your premiums?

Direct debitCheque (annually)

Credit/debit cardGroup scheme only

Premiums will be debited from your nominated account. Please complete the attached direct debit form.Note: 2.5% discount applies if selecting this method only on SmartCare plans.

All cheques must be made out to Accuro Health Insurance. Please ensure the name ofthe mainmember (as declared in section 1 of this form) is clearly stated on the reverseof the cheque.

Please attach the cheque to this application form.

Please complete the attached credit/debit card authority.

Note: 2% processing fee applies to credit/debit card payments.

Through your employerNote: Your employer-paid group scheme through Accuro may have the option for your portion of your premium to be collected from yourwages/salary. Please contact your employer or adviser if unsure.

Financial Strength RatingAccuro has achieved a BB+ Standard & Poors Financial Strength Rating. A BB+ is co

nsideredthe highest speculative grade by market participants.The rating scale is:AAA (Extremely Strong) AA (Very Strong) A (Strong)BBB (Good) BB (Stable) B (Weak)CCC (Very Weak) CC (Extremely Weak) D (Default)Note: Ratings from AAto CCCmay be modified by the addition of a plus (+) or minus(-)sign to show relative standing within the major rating categories.


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9 9Declaration Please read carefully before signing

Information for applicants

Under the Insurance Companies Act 1994, Accuro Health Insurance is notrequired to have a rating because it provides health insurance only, andaccordingly, it has elected not to be rated. Accuro Health Insurance is alsoa registered financial service provider under the Financial Service Providers(Registration & Dispute Resolution) Act 2008.

Declaration and authorisation to obtain and use information

I/We, the person applying for this Accuro Health Insurance Plan, confirmthat I/we:

1.Agree that this application and any other information obtained/provided about persons to be included on my/our plan forms thebasis of the contract.2.Declare that the information I/we have given is correct and completeand that no material fact has been omitted. I/We undertake to advise

Accuro Health Insurance of any health condition or event that mayaffect me/us or any of the other people named in this application orany relevant information that may affect the policy between the dateI/we sign this application and the date I/we receive a MembershipCertificate from Accuro Health Insurance.3.Declare that any information supplied in this application, whetherwritten by me/us or not, is true and accurate and that I am/we areauthorised, where a person is less than 16 years of age, to act ontheir behalf.4.Have read and understand this declaration and authorisation andits applicability to the Privacy Act 1993 and Health Information Code

1994 (see below for further information).5.Understand the nature of the plan(s) chosen and believe they meetmy/our requirements.6.Understand that, upon issuance of the Membership Certificate,I/we have fourteen (14) days to cancel my/our plan(s) (14-day freelookperiod) and that, subject to no claims having been made,I/we will receive a full refund.7.Understand that, if the application is approved, cover will startfrom the date stated on the Membership Certificate issued byAccuro Health Insurance.

8.For the purpose of assessing this application, and any futureclaims, I/we authorise Accuro Health Insurance to request and obtaininformation and records about me/us and any other people in thisapplication. I/We authorise the following people to give you any suchinformation and records:Any doctor, medical specialist, health agency, hospital, theAccident Compensation Corporation or other relevant person,including another insurer or person relating to any other insurance


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held by me/us.9.In relation to any other people named in this application on theirbehalf, I/we confirm that:I am/We are authorised to complete the application on theirbehalf and to disclose to Accuro Health Insurance their personaland health information.I/We have made each of them aware of the contents of thisapplication and each of them confirms that the informationprovided on their behalf is true and accurate.Each of the people named in this application have authorisedme/us to sign this declaration on their behalf.Under the Privacy Act 1993 and the Health Information Privacy Code 1994,please note the following:

1.This proposal collects personal information about you in connectionwith the insurance you are seeking.2.The intended recipient of the information is Accuro Health Insurance.3.

You have right to access and request corrections subject to theprovisions of the Privacy Act 1993.4.While we intend to treat this information as confidential, there aresome situations where we may need to disclose information to a thirdparty. By signing this declaration, you authorise the following kindsof disclosures;a) For statistical purposes (where not individually identified).

b) For evaluation of claims under your policy.

c) For providing on-going client service and information.

5.By signing this declaration, you authorise Accuro Health Insuranceto give and obtain your records, including from other insurers andparties, which may include information relating to any other insuranceor claims previously made by you.Important information

1.This form represents your application to become a member ofAccuro Health Insurance and relates only to the plans indicated.2.Anything in this declaration purporting to the singular may, byinference, include the plural.

3.Accuro Health Insurance is the trading name of the Health ServiceWelfare Society Limited (as registered under the Industrial & ProvidentSocieties Act 1908). By making this application, you are acceptingthe rules of the Society, including obligations therein, and understandthat the rules may subsequently be changed. If you would like a copyof the current rules before making this application, please do nothesitate to ask.4.The Board of Directors of the Society reserves the right, at all times,


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to vary the terms and conditions and benefits of plans however itdeems appropriate.5.This application forms the basis of any contract that eventuates andmust be filled in truthfully and accurately. Applicants are obliged,beyond that which is requested, to volunteer information that wouldhave a material impact on the cover offered. If you have doubts,you should disclose the information to Accuro for determination ofsignificance.6.Premiums are subject to change on 21 daysnotice.I/We accept the terms and conditions (including the limitations andexclusions) of the policy, including Accuro Health Insurance General PolicyTerms and Conditions

Main members name in full

SignatureDate

Partners name in full

SignatureDate

Dependants name in full (aged 16 years and over)

SignatureDate


SignatureDate


SignatureDate

It is important that Accuro Health Insurance receives yourapplication within 10 working days of your signing this formor your application may become invalid. Once received, thisapplication will be valid for 45 days.


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AccuroApplication received by Accuro and assessed.

We assess your application and the information you haveprovided, including any pre-existing conditions.

Is further information required?

In some instances, we require additional informationto complete your application.

Your membership is loaded/health insurance plan is issued.You will receive our WelcomePack including your MembershipCertificate and policy document.On some occasions, exclusionsmay be applied due to apre-existing medical condition.We will contact your insurance adviser or youdirectly and outline what the requirements are.As a general rule for health insurance, we rely onthe information that you or your insurance adviser

provide us to be true, complete and correct.However, we may request medical information fromyour GP or specialist.Yes No


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Conditions of this authority to accept direct debits

1. The initiator:2. The customer may:3. The customeracknowledges that:4. The bank may:(a)Undertakes to give written notice to the acceptor of the commencement date, frequency andamount at least 10 calendar days before the first direct debit is drawn (but notmore than twocalendar months).In the event of any subsequent change to the frequency or amount of the direct debit, theinitiator has agreed to give written advance notice at least 30 days before thechange comesinto effect.

(b) May, upon the relationship that gave rise to this authority being terminated, give notice to thebank that no further direct debits are to be initiated under the authority. Upon

receipt of suchnotice, the bank may terminate this authority as to future payments by notice inwriting to me/us.(c)May, upon receiving an authority transfer form(dated after the day of this authority) signedby me/us and addressed to a bank to which I/we have transferred my/our bank account, initiatedirect debits in reliance of that transfer form and this authority for the account identified in theauthority transfer form.(a)At any time, terminate this authority as to future payments by giving written no

tice oftermination to the bank and to the initiator.(b) Stop payment of any direct debit to be initiated under this authority by theinitiator by givingwritten notice to the bank prior to the direct debit being paid by the bank.(c)Where a variation to the amount agreed between the initiator and the customer fromtime to time to be direct debited has been made without notice being given in terms ofclause 1 (a) above, request the bank to reverse or alter any such direct debit initiated by theinitiator by debiting the amount of the reversal or alternation of a direct debi

t back to theinitiator through the initiators bank, PROVIDED such request is made not more than 120 daysfrom the date when the direct debit was debited to my/our account.(a)This authority will remain in full force and effect in respect of all direct debits passed to my/ouraccount in good faith, notwithstanding my/our death, bankruptcy or other revocation of thisauthority until actual notice of such events is received by the bank.


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(b) In any event, this authority is subject to any arrangement now or hereafterexisting betweenme/us and the bank in relation to my/our account.(c)Any dispute as to the correctness or validity of an amount debited to my/our account shall not bethe concern of the bank except in so far as the direct debit has not been paid in accordance withthis authority. Any other disputes lie between me/us and the initiator.(d) Where the bank has used reasonable care and skill in acting in accordance with this authority,the bank accepts no responsibility or liability in respect of:the accuracy or information about direct debits on bank statementsany variations between notices given by the initiator and the amounts of directdebits.(e)The bank is not responsible for, or under any liability in respect of, the initiators failure to givewritten advance notice correctly nor for the non-receipt or late receipt of notice by me/us for anyreason whatsoever. In any such situation, the dispute lies between me/us and theinitiator.(f)Notice given by the initiator in terms of clause 1 (a) to the debtor responsible

for the paymentshall be effective. Any communication necessary because the debtor responsible for payment isa person other than me/us is a matter between me/us and the debtor concerned.(a)In its absolute discretion, conclusively determine the order of priority of payment by it of anymonies pursuant to this or any other authority, cheque or draft properly executed by me/us andgiven to or drawn on the bank.(b) At any time, terminate this authority as to future payments by notice in writing to me/us.(c)

Charge its current fees for this service in force from time to time.(d) Upon receipt of an authority to transfer formsigned by me/us from a bank to which my/ouraccount has been transferred, transfer to that bank this authority to accept direct debits.


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Credit/debit card authority

Fill in the required details clearly in BLOCK CAPITALS and make sure that you have signed this form and supplied yourcontact phone number. Please return this form to Accuro or your adviser.

Your credit/debit card will be charged on the nominated payment date.

We will automatically adjust the payment amount when changes happen to your policy and notify you in advance of thepayment date. You dont have to fill in another form.

This information is being collected by Accuro Health Insurance for administrative purposes, including billing. You havethe right of access to, and to request correction of, any personal information held by us.

If you need any further information, just call us toll free on 0800 222 876 andone of our Member Services team willhelp you.

Your details

Membership number(if assigned)Main members nameDaytime phone number

Weekly Fortnightly MonthlyRecurring payment frequencyOne-off paymentRecurringAmount $SelectName that appears on the cardPreferred date of first payment

or

As soon as possible

dd mm yyyy

Credit/debit card

Visa*

Mastercard*

Expiry date on cardmm yyCard numberPlease remember, when your credit/debit card expires, you will need to completea new form.

I/We authorise Accuro Health Insurance, until further notice in writing, to charge my/our credit/debit card account with


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all amounts due on my/our Accuro Health Insurance account from time to time, onor after the payment due date.

Cardholder signature

dd mm yy

* Please note that we only accept Visa or Mastercard. We do not accept other cards such as American Express or Diners Club.


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79 Boulcott StreetPO Box 10075, Wellington 6143New Zealand

Freephone 0800 ACCURO (0800 222 876)

Email [email protected] 04 473 6187www.accuro.co.nz

Accuro Health Insurance is the trading name forthe Health Service Welfare Society Limited, which isincorporated under the Industrial and Provident Societies Act 1908.

A4BK-220-11/2011


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Documents

ACC5903 Application Form FSR