Forms Clearance Request "*" 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 Name* Last Name* Address Address City State Postcode Contact DetailsHomeMobile*WorkPrevious Health Fund DetailsPrevious Fund Name*Policy No. (if Known)Effective Date*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date Paid to*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DependantsPlease list all dependants*NameDOB (dd/mm/yyyy) Add RemoveClick the + icon to add moreNew Fund DetailsFund Name: Hunter Health Insurance (CDH)Policy No. (If Known)Start DateDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 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 attachments Drop files here or Select files Max. file size: 32 MB. Signature*EmailThis field is for validation purposes and should be left unchanged.
