"*" indicates required fields Please complete the below form to submit your request. Membership NameName* Member Number* Change of Contact DetailsNew Address Street Address Address Line 2 City State Postcode New Email Address New Telephone Details(H)(M)(W)Add / Remove DependantWould you like to remove a dependent, add a dependent or both? Add Remove Both Add a DependentNameDOBRelationship Add RemoveRemove a DependentNameDOBRelationship Add RemoveCover DetailsMembership Type Single Family Ambulance Ambulance Additional Ambulance Only Hospital Cover Silver + Hospital Hospital Cover Excess Nil Excess $250 Excess $500 Excess $750 Hospital Cover Silver + Pregnancy Hospital Hospital Cover Excess $250 Excess $500 Hospital Cover Silver + Saver Hospital Hospital Cover Excess $250 Excess $500 Hospital Cover 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 Please upload all relevant attachmentsChange of NamePrevious Name New Name FileMax. file size: 32 MB.Signature*EmailThis field is for validation purposes and should be left unchanged.