> _Markdown transcription of UniMed Health Positive policy wording, effective 2016-01-22. Source: http://www.unimed.co.nz/images/pdf/833UNIM-Health%20Positive%20Plan%20Brochure%20-Online%20Application%20Form.pdf_ --- # Application Form: Union Medical Benefits Society Limited (UniMed) ## Application Form ### Personal Details **Title:** (please circle) Mr/Mrs/Miss/Ms **Name of applicant** - First name - Middle name - Surname **DOB of applicant:** DD/MM/YYYY **Gender:** (please circle) Female / Male **Address of applicant** - Street - Suburb - City - Postcode **Contact Phone** **Cellphone** **Email** Please use another form for each additional family member ### Nature of Plan **Level of reimbursement (Tick)** - 50% - 80% ### Premium Payment Options **I wish to pay my premium:** - Annually - Monthly - Weekly **And by the following method:** - Direct debit - Cheque (Payable to UniMed) - Recurring credit card payment - Internet banking (02-0865-0154711-00) - annual payment only ## Important Information 1. This form is your application to become a member of the Union Medical Benefits Society Limited (UniMed), which administers health insurance plans for members. 2. "Acceptance" by UniMed will not have immediate binding effect. You will be afforded a period in which to consider the extent of the cover UniMed is prepared to provide, any exclusions, the Conditions of Membership, and the like. 3. UniMed is registered under the Industrial and Provident Societies Act 1908. Like all societies, it has rules which will bind you. The Rules govern the way UniMed is run and the Health Insurance Plans it administers. The Rules are subject to change. If you want a copy of the current rules before making this application, please feel free to request a copy. ## Privacy Declaration Pursuant to the Privacy Act 1993 (and the Health Information Privacy code 1994) the following is brought to your attention: i. Your application collects personal information about you and other named applicants to enable Union Medical Benefits Society Limited to evaluate and administer the cover you seek. ii. You are required by law to disclose information that is relevant to the cover you require. Failure to provide this information may result in your application for cover being declined or your cover being void. iii. This information will be held by the Union Medical Benefits Society Limited whose Head Office is 211 Ferry Road, Christchurch, and any agency involved in completing your application. iv. You have the right to access and to request correction of this information, subject to the provisions of the Privacy Act 1993. v. UniMed will, in the main, be able to treat the information you supply as confidential between you and us. There are some situations however where this will not be possible. These are: - A. To offer the best acceptance terms, we may need to share the information with reinsurers - B. Statistical purposes (you will not be identified) ## Applicant's Declaration 1. I acknowledge having read and understood the significance of the 'Important Information' contained in this Application Form. 2. I declare all entries made on this form to be true and correct and that I am not aware of any other circumstance which might affect the risk of insurance on my health or that of any other person listed on my application. I acknowledge that failure to make this declaration truthfully may invalidate my insurance. 3. I understand that the Society's Membership/Sales Representative does not have authority to advise me upon such disclosure and that the said Representative has explained the terms and conditions of the Society. 4. I understand that the written declaration in the Application Form constitutes the basis of the contract with the Society. No oral representations, inducements, statements or promises made by or on behalf of either party, including the Sales Representative, and not contained in the Application Form or the brochure for the Health Plan selected shall be relied upon or binding. 5. I agree that any payment accompanying this application shall be a deposit only and I understand that any coverage will not commence until the Society has issued a Membership Certificate. 6. I understand that any special joining concessions or restrictions of cover in relation to my declared existing conditions will be shown on my Membership Certificate. 7. I authorise the obtaining of any personal medical information the Society may require in respect of this application or future claims as submitted by me, from any doctor who has attended or examined me or my listed dependants. 8. I agree to be bound by the Rules of the Society and the Conditions of Membership. ## Signature and Date **Signature:** _____________________ **Date:** _____________________ ## Office Use Section | Agent Code | Membership # | Date Received | Date Effective | |---|---|---|---|