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Home > Health Insurance > Overseas Visitors > Healthy Travel Application

Healthy Travel Application Form

Application Details

Required fields: All fields with a * must be completed before you can proceed to the next step.


My details

Title* First name* Middle name Surname*

Date of Birth:* (DD/MMM/YYYY)   Gender:*
   Male   Female  

Address in Australia, if known

City/Town
 		State
 		Postcode

Address in Country of Origin*

City/Town*
 State/Province*
 Postcode/Zip Code*
Country*

We require at least one contact phone number.*
Phone (Home)
 Phone (Work)
 Phone (Mobile)
Please include country code and local area code

E-mail Address (required for policy confirmation)*
e.g. user@yourserver.com.au




Cover Type*

Single   Family  



Extras Cover

Do you wish to have Extras Cover?




Dependant details (required for family covers)

Definition of a dependant or student dependant
Dependants surnames are only required if they are different from yours.
Dependant 1 - Spouse, Defacto or Partner
Title First name Surname

Date of birth		 Gender:
Male  Female 



Dependant 2
First name Surname

Date of birth
Gender:
Male  Female

Relationship to you: 



Dependant 3
First name Surname

Date of birth
Gender:
Male  Female

Relationship to you: 



Dependant 4
First name Surname

Date of birth
Gender:
Male  Female

Relationship to you: 






Pre-Existing Medical Conditions*

IMPORTANT - YOU MUST COMPLETE THIS SECTION FULLY

Do you, your spouse/defacto/partner or dependants have any ailment, disability, illness or condition that may require treatment? (Please refer to the Waiting Periods section.)

Yes   If yes, please give details below.
No

Details of condition, including name of sufferer, if relevant.



Cover Commencement*

What date do you wish to commence your cover?
(Cannot be backdated)

How long do you wish to purchase cover for?
3 Months
6 Months
12 Months



Declaration*

By typing "Yes" at the end of this Application Form, I accept and agree to abide by the health benefit fund rules of Australian Unity Health Limited (ACN 078 722 568) and I understand the rules regarding the pre-existing conditions, elective procedures, waiting periods and benefit exclusions (where applicable) which are listed in full in the Terms and Conditions for Healthy Travel and (where applicable) Terms & Conditions for Extras for Healthy Travel. I confirm that the date of birth details and all other information provided on this application form are true and correct.

I acknowledge that the personal information Australian Unity collects from me is collected for the purpose of processing this application, fulfilling Australian Unity’s obligations in providing services to me, for the development of products and services, and to allow the Australian Unity Group to market products and services. A current sample of these products and services is contained on the Site Map. By typing "YES" in the space below, I consent to the Australian Unity Group collecting and using this information for these purposes.

I acknowledge that if I apply for Healthy Travel cover following use of a weblink provided by a Migration agent, Education agent or Broker, Australian Unity may forward a duplicate copy of my confirmation email to the agent or broker. I agree to the confirmation email containing my personal details provided in the application.

I understand that this application does not become effective until acceptance of this application by Australian Unity.

To apply, please type "YES" in the space below.


   


 
 

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