Forms New Member Application "*" indicates required fields Please complete the below form to submit your request.Membership ApplicationGiven Name*Surname*D.O.B*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Male Female Other Address* Address City State Postcode Postal Address As Above Address* Address City State Postcode Contact DetailsHomeMobileWorkEmail Address* Company Name (if applicable)Family & Dependant DetailsGiven NamesRelationshipDOB (dd/mm/yyyy)Gender Add RemoveClick the + icon to add moreCover DetailsMembership Type* Single Family Ambulance Ambulance Additional Ambulance Only Hospital Cover Silver + Hospital Silver + Pregnancy Hospital Silver + Saver Hospital Bronze Hospital $500 Excess Only Bronze Packaged Single (Nil Excess Only) Basic Hospital (Nil Excess Only) Extras Cover Premium Extras Hunter Extras Healthy Extras Ideal Extras Silver + Hospital* Excess Nil Excess $250 Excess $500 Excess $750 Silver + Pregnancy Hospital* Excess $250 Excess $500 Silver + Saver Hospital* Excess $250 Excess $500 Payment DetailsPayment Options:* BPAY Direct Debit (Card or Bank Account) Payment Type* Bank Account Credit or Debit Card BSB*Account Number*Name on Account*Card Number*Expiry Date*Name on Card*Current Insurance DetailsAre you transferring from another health insurer?* Yes No What is the name of your current health insurer?*Please provide your member or policy number with your current health insurer*Why is this required? To ensure a seamless transition we need to issue a clearance certificate to your current insurer with your current member number for identification.What date is your current policy effective to?*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What date would you like to start your policy with Hunter Health Insurance?*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Documents ChecklistThe following documents are required to complete your application. Mandatory Documents Licence or Passport Medicare Card Optional Documents Student Declaration Health Care Card Pension/ Health Number Please upload all relevant documents Drop files here or Select files Max. file size: 32 MB. Pre - Existing IllnessDo you or any members have any illness pre-existing? Please indicate below: Yes No Please list any pre-existing illnessesMembership Consent* Membership Consent*I hereby wish to apply for membership to Hunter Health Insurance (CDH) and agree to abide by the rules and regulations as laid down by this organisation. I would further certify that neither myself nor any dependant covered under this membership, has to the best of my knowledge any pre-existing or chronic illness other than those listed at the date of this application.Clearance Request Consent* Fund Transfer Consent*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.Direct Debit Consent* Direct Debit Consent*I / we request Cessnock District Health Benefits Fund Dr - 088892 to arrange for funds to be debited from my nominated financial institution as provided above. Please note: Joint Accounts require both signatures.Signature - Primary Account Holder*Signature - Secondary Account HolderIf there is more than one adult on this policy, please have the secondary account holder sign here.EmailThis field is for validation purposes and should be left unchanged.
