"*" indicates required fields Please complete the below form to submit your request. Member Number* Member Name* Contact Details During SuspensionNew Email Address* PLEASE NOTE: EMAIL WILL BE THE FORM OF COMMUNICATION.New Telephone Details(H)(M)(W)Suspension PeriodsDeparture Date DD slash MM slash YYYY Re-Entry Date DD slash MM slash YYYY Check Lists E-Ticket Intinerary Other (Please Specify Below) Please upload all relevant attachments.FileMax. file size: 32 MB.I declare that the information that I have provided on this form is true and correct. I understand the terms and conditions provided, I wish to suspend my membership:*SignatureConditionsSuspension of membership for overseas travel (contact the Fund for full details)You can apply for 'Suspension of Membership' if you are travelling overseas and will be out of Australia for a continuous period of not less than 2 months to a maximum of 24 months, This will allow you to freeze your cover and not have to pay contributions for that period outside of Australia provided all persons listed on that membership will also be travelling for the same period. Your membership will be resumed to the same level of cover prior to your date of travel except for any condition or ailments that arise during the period of suspension which will be treated as pre-existing conditions and the appropriate waiting period apply. Please understand that No Benefit will be considered if the service was incurred during the suspended period.Suspension of a Policy may be granted by Hunter Health Insurance (CDH) for any other reason and for any other period that Hunter Health Insurance (CDH) considers appropriate until such time as a further Premium is paid provided that such payments are resumed from the date as directed by Hunter Health Insurance (CDH). Further suspension of a Policy will only be granted six months after return of the previous suspension and financially covered for that period.With your request to suspend membership for travel purposes, you must submit supporting documentation for all persons covered on your membership prior to your departure. Documentation includes itineraries and e-tickets. If no evidence of your travel for the period of suspension requested is received, no suspension will be applied to your membership.On returning to Australia you must reinstate your membership within 1 month and pay commencing from the date of return, and supply evidence of the date you returned to Australia. If no evidence is received your suspension will be cancelled and may have Lifetime Health Cover implications.Please understand that any suspended cover may affect your Medicare Levy Surcharge, please contact the Australian Taxation Office (ato.gov.au) for details.EmailThis field is for validation purposes and should be left unchanged.