Local Government Employees Health Plan Application March 2014

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1 Local Government Employees Health Plan Application March I wish to (please tick) Join GMHBA Transfer from an existing GMHBA membership Change my cover GMHBA member number (existing members only) Cover or change of cover to commence from / / Cover does not commence until payment is received Council/Employer: 2. Type of cover Single Family/couple Single parents 3. My details Title Member number Address Suburb/city State Postcode Postal address (if different) Suburb/city Postcode Date of birth Sex Male Female Phone Mobile address Fax I would like to receive the Great Health magazine, as well as invitations to member events, special offers and preventative health information from GMHBA. Please keep the Important Information Guide with your other GMHBA documents 4. Partner authority (optional for application to sign I authorise the person identified as my partner/spouse on the application form to make changes to this membership, including varying the level of cover. Signed Date / / 5. Other people to be covered I confirm all people covered under my GMHBA membership are citizens or permanent residents of Australia who have full Medicare eligibility. Note: Children under 21 are covered under family memberships. Children over 21 and under 25 are covered if they are single and undertaking a full-time apprenticeship, full-time traineeship or full time study at eligible educational institutions (please see below). (include surname if different to applicant) Relationship Date of birth M/F Given name / / Educational institution Given name / / Educational institution Given name / / Educational institution

2 Hospital Gold Hospital Gap Saver With Pregnancy No Pregnancy Level 0 (nil excess) PGHO PGNO PGH1 PGN1 PGH2 PGN2 Gold Hospital With Pregnancy No Pregnancy Level 0 (nil excess) GH0 GN0 GH1 GN1 GH2 GN2 Silver Hospital Level 0 (nil excess) Bronze Hospital Level 0 (nil excess) SH0 SH1 SH2 BH0 BH1 BH2 FIT Packages FIT Ultra Package FIT Top Package FIT Standard Package FIT Entry Package XMa1Ma8 XMa2Ma8 XMa1Mi8 XMa2Mi8 XBa1Mi8 XBa2Mi8 XBa100B XBa200B Extras Set benefits Percentage back Gold Extras GS G75 Silver Extras SS S65 Bronze Extras BS B55

3 6. Transferring from another health fund Health fund Cover name Member number Date joined / / Date paid to / / If you are transferring from another health fund, please attach a transfer certification form. Or, you can complete the attached Transfer Certificate Request form if you want GMHBA to terminate your membership and request a transfer certificate on your behalf. 7. Direct credit of claims benefits Please direct credit my benefits on paid account into the bank/building society/credit union account nominated below BSB number / Account number Name (s) the account is held in Bank name Branch If you are unsure of the BSB number, please contact the bank where the account is held 8. Method of payment Automatic payment from credit card (please complete Credit Card Authorisation form) Cash, cheque, BPay or BillPay each Monthly Quarterly Half-yearly Yearly Payroll deduction Employer 9. Privacy Prior to signing and submitting this Application Form, you must: - read the latest version of the GMHBA Health Insurance Privacy Statement; and - ensure any spouse/partner and adult dependant children who are to be covered by your GMHBA Health Insurance membership are aware of and consent to how their personal (including sensitive) information is handled by GMHBA Limited in accordance with our Privacy Statement. I declare that I, as well as all other adult persons to be covered by my GMHBA Health Insurance membership, have read, and consent to the collection, use and disclosure of our personal (including sensitive) information in accordance with the GMHBA Health Insurance Privacy Statement. 10. Declaration (applicant to sign) The signing of this application and the payment of any premium shall constitute an acceptance of the above privacy decleration and conditions laid down by the regulations in force at this time or as may be amended from time to time. I understand proof of identity including age may be required to confirm the details of persons listed on this application, the rulings regarding preexisting conditions/illness, waiting periods and the conditions of membership. I declare the above statements/information to be true and correct Signed Date / /

4 Application to receive or change the Australian Government Rebate on Private Health Insurance as a reduced premium Complete this registration form and lodge it with GMHBA Health Insurance to receive the Australian Government Rebate on Private Health Insurance. All the people listed on the policy must be eligible to claim Medicare for you to receive the rebate as a reduced contribution. If at any stage you wish to stop receiving the Australian Government Rebate on Private Health Insurance as a reduced premium, you must notify GMHBA Health Insurance as soon as possible. Employers and trustees of organisations cannot claim the Australian Government Rebate on Private Health Insurance on policies paid on behalf of employees. Name of private health fund issuing the policy to which this application relates: GMHBA Health Insurance Membership number: Are you covered by this policy? Yes No Date contribution reduction commenced: / / Please nominate your rebate tier (refer to the GMHBA Member Guide for more detail): Your age Base Income Tier Income Tier 1 Income Tier 2 Income Tier 3 Singles $88,000 or less $88,001 - $102,000 $102,001 - $136,000 $136,001 or more Families/Singles $176,000 or less $176,001 $204,000 $204,001 -$272,000 $272,001 or more Under 65 Between 65 and and over For more information on which level is appropriate please read the GMHBA Important Information Guide. Your full name as it appears on your Medicare card: Your Medicare card Number: Valid to: / / Your current postal address: Your residential address: Your daytime phone number: Work: Home: Your date of birth: / / Sex: Are all the people on the policy listed on a Medicare card or entitled to a Medicare card? Yes No Details of all people covered by the policy: Name: Date of Birth: Relationship/Dependant Child: Gender: A child is a dependant if: the child is under the age of 21 years, or a full-time student under the age of 25. the child is covered by your insurance policy and GMHBA Health Insurance accepts the child as a dependant child on the policy. the child is not a partner of another person. You are entitled to a Medicare card if: you are a person who lives in Australia: you are an Australian citizen; a holder of a permanent resident visa; a New Zealand citizen, or, in some cases an applicant for a permanent resident visa. Any inquiries about Medicare eligibility can be made at any Department of Human Services service centre or by phoning Declaration: I declare that the information I have provided is correct. I understand that there are penalties for giving false or misleading information. Signed: Date: / / Please send this registration form to GMHBA Health Insurance at the address below. Privacy Note. The information provided on this form will be used for the purposes of registering you for the Australian Government Rebate on Private Health Insurance. Its collection is authorised by Private Health Insurance Act This information may be disclosed to the Department of Health and Ageing, Department of Human Service and the Australian Taxation Office or as requested or required by law.

5 Transfer Certificate Form Please complete this form if you want GMHBA to terminate your membership with another health fund and request a transfer certificate and claims history on your behalf. This form must be signed by the member who has legal responsibility for membership of your previous fund. Health Fund: Member Number: Member Name: Full names and dates of birth of all people who you wish to cancel and transfer to GMHBA: address: Street address: Suburb/city: State: Postcode: I authorise GMHBA to cancel my Hospital only Extras only Combined cover with your fund from: Date / / Signed Date / / Please find my premiums paid in advance of the cancellation date and send a transfer certificate and claims history for all people covered under my membership to GMHBA. Remember, continuity of a member s/partner s certified age at entry (CAE) is possible when transferring from another Australian registered health fund under Lifetime Health Cover. Please do not contact me further about this request.

6 Credit card authorisation Member name Date / / Member number Phone address Address Suburb/city State Postcode I hereby authorise GMHBA Limited to charge my credit card A on this occasion for the amount of $ B automatically, each Month Quarter Half year Year Until instructed by me in writing to cease deductions. I understand that the first credit charge will occur on / / (first working day of the month). I also authorise GMHBA Limited to charge my credit card such amount as is required to pay the member s premium up to the next charge date. If the premium changes or payments are in arrears, I authorise GMHBA Limited to alter the amount from the appropriate date in accordance with such changes. Alterations/cancellations to membership or account details must be received in writing on the prescribed form/s at least seven days before the next scheduled direct debit deduction date. A refund of premiums cannot be issued within 14 days of the debit date. This allows sufficient time for the financial institution to advise GMHBA of any debit deduction dishonour. After two consecutive dishonours, GMHBA will remove the membership from the debit scheme. Type of credit card Mastercard Visa Card Card number Expiry date / / Cardholder s name (If different from member name) Cardholder s signature

7 Payroll Authority Form Employee Details Employer: Payroll Number: Employee Name: Employee Street Address: Suburb: State: Postcode: GMHBA Membership Membership Number: Other Member Numbers covered by this authority: Deduction Details: Please deduct from my pay: Weekly Fortnightly Monthly Amount to be deducted (Total amount of all policies listed above): $ Declaration I hereby authorise you to deduct from my pay until further notice and pay the amount so deducted on my behalf to GMHBA Limited, Moorabool Street, Geelong. This is a new authority and cancels any previous authority for GMHBA Limited or any other Medical and Hospital Bene ts Organisation. Should the fund alter the contribution rate of the schedule under which I am now covered in accordance with the National Health Act, the amount deducted from my salary or wages shall be varied accordingly as from the date of the receipt by you of notice in writing from the Association. In consideration of this deduction being made, I indemnify the above mentioned Employer and employees thereof against any failure to make deductions and remittances as authorised herein. Employee Signature: Date: / / O ce Use Only Payroll Group: Group Number: GMHBA Limited Page 5

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