"*" indicates required fields Please complete the below form to submit your request. All Australian registered health funds are required to issue you with a Clearance Certificate when you cancel your health cover with them. This is to ensure any waiting periods have been served and to recognise your Lifetime Health Cover details. To allow us to obtain these details and/or advise your previous Health Fund your intentions to transfer your cover to us, please complete the details below and sent this form (signed and dated) to the above address via mail, scanned email or fax.Members DetailsName* First Last Address Street Address Address Line 2 City State Postcode Contact Details(H)(M)*(W)Previous Health Fund DetailsPrevious Fund Name*Policy No. (if Known)Effective Date* DD slash MM slash YYYY Date Paid to* DD slash MM slash YYYY DependantsPlease list all dependants*NameDOB Add RemoveCLICK THE + ICON TO ADD MORENew Fund DetailsFund Name: Hunter Health Insurance (CDH)Policy No. (If Known)Start Date DD slash MM slash YYYY I hereby authorise Hunter Health Insurance (CDH) on my behalf to obtain the Clearance Certificate and cancel my membership including any payment arrangements with from the start date of my policy with Cessnock District Health Benefits Fund. Please upload all relevant attachmentsFileMax. file size: 32 MB.SignatureEmailThis field is for validation purposes and should be left unchanged.