Please complete the below form to submit your request. Membership ApplicationGiven Name* Surname* D.O.B* DD slash MM slash YYYY Gender Male Female Address Street Address Address Line 2 City State Postcode Postal Address Contact Details(H)(M)(W)Email Address* Family & Dependant DetailsGiven NamesRelationshipDate of BirthMale/Female/Other Add RemoveCover DetailsMembership Type Single Family Ambulance Ambulance Additional Ambulance Only Hospital Cover Silver + Hospital Young Silver + Hospital (Nil Excess Only) Thrifty silver Smart Bronze Cover (Single Cover, Nil Excess Only) Basic Hospital (Nil Excess Only) Excess $250 Excess $500 Extras Cover Elite Extras Optimum Extras Classic Extras Healthy Extras Ideal Extras Contribution DetailsPayment Type: Contribution Amount: Certified Age of Entry to a Fund: HHI (CDH) Start Date Required: Checklist Licence or Passport: Federal Government Rebate Form: Student Declaration: Medicare Card: Health Care Card: Pension/ Health Number: Pre - Existing IllnessDo you or any members have any illness pre-existing? Please Indicate below: Yes No Member DeclarationAre you transferring from another fund? Yes No 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. I have completed the Federal Government Rebate Form and the Direct Debit Details Form.Please upload all relevant attachmentsFileMax. file size: 32 MB.Signature*