Clearance Request

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 Details

Name*
Address

Contact Details

Previous Health Fund Details

DD slash MM slash YYYY
DD slash MM slash YYYY

Dependants

Please list all dependants*
Name
DOB
 
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New Fund Details

DD slash MM slash YYYY

Please upload all relevant attachments

Max. file size: 32 MB.