SENSIS CORPORATE HEALTH PLAN

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1 SENSIS CORPORATE HEALTH PLAN The Health Insurer - Navy Health The health insurer for the Sensis Health Plan is Navy Health - a not-for-profit, member based Fund. Navy Health is one of Australia s restricted membership health funds - which means not everyone can join. However through the Sensis Corporate Health Plan, all Sensis employees have eligibility to join and enjoy the great protection and premiums available from Navy Health. Importantly, when you join Navy Health through the Sensis Corporate Health Plan your entire immediate family also becomes eligible to join the fund. So your siblings, parents, adult children, grandparents and grandchildren can join Navy Health in their own right and start enjoying Navy Health s exceptionally competitive premiums (family members covered by their own membership cannot join the Sensis Corporate Health Plan but take out any of Navy Health s other excellent health cover products). Excess Refund Health Insurance is like car insurance. When you choose a policy with an excess, you save with large premium discounts. Of course, the downside is that you need to pay the excess if you make a claim on your policy. That s where the Corporate Health Plan is different... Through this special workplace amenity, your excess will be refunded to you if you, or an eligible family member goes to hospital. That means you can save by taking a hospital cover option with an excess but still enjoy the security, peace of mind and finacial protection of nil excess cover. The Plan offers employees a range of health cover options for you to choose from including hospital and extras covers for families and couples, single parents and singles. Joining the Corporate Health Plan is easy! Simply select your Navy Health cover from the family, couple, single parent or singles options and then complete and return the Application Form (including the Credit Card or Direct Debit Authority) to Health Link Consultants. Post: Reply Paid 13107, Health Link Consultants, PO Box 13107, Law Courts VIC 8010 Fax: (03) or Need Help? The Corporate Health Plan offers employees and their families the security of private health cover and great premium savings. If you are unsure which cover best suits your needs, call Health Link Consultants on to discuss your situation or health cover requirements.

2 (Form A) Membership Application 1. I would like to apply for (please tick) New Corporate Health Plan Changing my cover/membership details Transfer from another Fund Cover to commence : 2. My Details (Contributing member) Sensis Employee ID: Title: Address: Suburb: State: Postcode: Phone (Business Hours): Phone (After Hours): Mobile: Gender M/F 3. Other people to be included on the Membership

3 (Form A) Membership Application continued Authority to Operate Membership Do you authorise a person, other than yourself, to operate this membership? (eg. partner, power of attorney*) Yes No Name: Relationship: To operate membership or To query membership only Please Note: Unless a Power of Attorney is supplied, Medical details of Adults on a membership will not be provided to anyone except the patient. Dependant information will be provided to Member only. *Requires appropriate documentation to be provided. 5. Choice of Cover Couple Single Single Parent Family Dependant Only Family 6. Choose the Corporate Health Plan you require (please tick) Hospital Cover Corporate Health Cover 200 Corporate Health Cover 500 Extras Cover Premium Extras Heathly Living Extras Basic Extras 7. Promotional Code If you have a promotional code relevant to your application, please enter below: 8. Signature: I have read and understood the information and conditions associated with my policy and accept to abide by the rules of the fund. I acknowledge that I have read, understood and retained the information contained in this brochure. Signed

4 (Form B) Payment Options Name: Frequency of Payment Monthly For the amount of $ Half Yearly For the amount of $ Yearly For the amount of $ Choice of Payment 1 Credit Card (Go to option A) 2 Direct Debit Request (Go to option B) Option A: Credit Card Authority Visa Mastercard I/We request Navy Health to debit ongoing funds from my nominated credit card. This authorisation is to remain in force until I notify Navy Health of any change. If my premium for my cover changes, I authorise Navy Health to alter the amount to be charged, from the appropriate date,and for the appropriate amount. Name on card: Card Number: Expiry : Signed Option B: Direct Debit Request I/we request Navy Health (Id. No 25776) to debit funds from my/our nominated account according to the details specified below through the Electronic Banking System. This authorisation is to remain in force in accordance with the terms described in the Direct Debit Service Agreement (as specified on page 32). Details of your Account Financial Institution: Account Name: BSB Number: / Account Number: I/we request that you debit the amount listed above, at the payment frequency specified. The exact debit amount will under normal circumstances reflect your regular premium however debits may vary if payment amounts are not received within stated guidelines. I/we authorise the following: 1. The direct debit user to verify the details of the above mentioned account with my/our Financial Institution. 2. The Financial Institution to release information allowing the debit user to verify the above mentioned account details. Signed by the customer/s:

5 (Form C) Application to receive the Federal Government Rebate Please complete and sign this section if you wish to receive the Federal Government Rebate for private health insurance as a reduced premium. I wish to apply for the Federal Government Rebate of: 30% (the eldest person listed on the membership is aged less than 65 years) 35% (the eldest person listed on the membership is aged years) 40% (the eldest person listed on the membership is aged 70 years plus) All people on your membership must be listed on a Medicare card or be entitled to a Medicare card for you to receive the Rebate. You must have a current Medicare card. If your Medicare card is out of date, you cannot qualify for the Rebate until you obtain a new card from Medicare. 1. Your Medicare card number: 2. Valid to: / 3. Your name and subnumerate digit exactly as it appears on your Medicare card: 4. List other members on this card and their subnumerate digit: 5. Are all the persons on the Navy Health Policy listed on a Medicare card or entitled to a Medicare card? Yes No 6. Declaration I declare that the information provided is correct. I understand that there are penalties for giving false or misleading information. Signature The information provided by you on this form will be used for the purpose of registering you for the Federal Government Rebate for private health insurance. Its collection is authorised by law, and information collected will be disclosed to the Department of Health and Aged Care,the Health Insurance Commission and the Australian Taxation Office.

6 (Form D) Clearance Transfer Certificate You need to complete this section if you are transferring your membership to Navy Health from another fund. Please use this form to authorise Navy Health to terminate your membership with your existing health fund, and to request a Clearance Transfer Certificate on your behalf. This must be signed by the current contributor of your previous fund. If you have a direct debit or salary deduction arrangement with your existing fund, please remember to personally cease the payment arrangement. Clearance Certificate Request Form: Title Address: Gender M/F: Suburb: State: Postcode: List all other persons transferring: Name of existing Health Fund: Membership Number: Year Joined: paid to: Cover: I hereby authorise Navy Health to terminate my membership with your organisation with effect from: I further request you to forward a Clearance Certificate directly to Navy Health, PO Box 172, Box Hill, Victoria, 3128 OR fax (03) Navy Health is authorised to obtain full details, including claims history, about myself and all other members on my membership. Signature

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