Young Adult Membership Application Form

Parent Navy Health Details:

Parent Main Policy Holder First Name*

Parent Main Policy Holder Last Name*

Membership Number*

Young Adult Details:

Title*

First Name*

Last Name*

Street Address*

Suburb*

State:*

Postcode*

Phone Number*

Date of Birth*

Email Address*

How would you like to receive your membership information:*

SMS
Email

Would you like others to operate your membership?

Do you authorise another person to operate this membership? (e.g. parent, power of attorney^)*

Yes
No

^Requires Power of Attorney documentation to be provided.

First Name

Last Name

Relationship

Do you authorise this person to:

Operate your membership
Query your membership

Extras Cover:

What level of extras cover do you require?*

Premium Extras
Healthy Living Extras
Budget Extras

Date to commence from:*

Payment options:

I authorise the following payment option:*

Fortnightly
Monthly
Half-yearly
Yearly

Payment method:*

Direct debit – bank/financial institution
Direct debit – credit card

If you would prefer to pay your premium with a credit card, we will contact you regarding your payment as Navy Health cannot request credit card information via application form.

I/we request Navy Health (Id. No. 25776) to debit funds from my/our nominated account according to the details specified below through the Electronic Banking System. This authorisation is to remain in force in accordance with the terms described in the Direct Debit Service Agreement. If my premium for my cover changes, I authorise Navy Health to alter the amount to be charged, from the appropriate date, and for the appropriate amount.

I agree

To view the Direct Debit Service Agreement, please click here.

Financial institution

Account name

BSB number

Account number

I/we request that you debit the premium for my chosen level of cover. The exact debit amount will under normal circumstances reflect your regular premium however debits may vary if payment amounts are not received within stated guidelines. I/we authorise the following: 1. The direct debit user to verify the details of the above mentioned account with my/our financial institution. 2. The financial institution to release information allowing the debit user to verify the above mentioned account details.

I agree

I/we authorise claim payments to be paid back into the above nominated account.

I agree
I disagree

Government Rebate Form

Thank you filling out the application form. To finalise your application, please complete the Government Rebate Form and upload it below. The rebate is an incentive to take out private health insurance. Depending on your income and age the rebate can help you reduce your premium, so you may pay less while getting the benefits private health cover has to offer.

Max. file size: 50 MB.

If you are applying for the Government Rebate, please specify when you would like the premium reduction to commence (this will usually be the start date of your policy):*

I have read and understood the information and conditions associated with my policy and agree to abide by the rules of the fund. I acknowledge that waiting periods for extras cover may apply.*

I agree

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Email

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Online Member Services

Online Member Services