Southern Cross Health Society


    Application form

    You can apply for Health Essentials in less than five minutes. Have your payment information handy.

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    Information about you, the policyholder



    Date of birth


    Mobile number

    Email address We'll be sending notifications via email so make sure you give an email address you check regularly.

    Confirm email address

    Employment details

    Name of company

    Staff number

    Branch / department



    Are you or any family members named in your application currently a member of Southern Cross? This application is for a new HealthEssentials policy only and not for changing an existing policy to HealthEssentials. If you are an existing member wanting to change plans, give us a call on 0800 800 181.

    Are you and all family members named in this application, entitled to all publically funded healthcare services in New Zealand (i.e. New Zealand Citizens, New Zealand Residents, holders of a resident Visa or otherwise entitled as determined by the Ministry of Health)?To apply for HealthEssentials you need to be eligible for all publically funded health and disability services. Publically funded health and disability services are available to New Zealand Citizens, New Zealand Residents, holders of a resident Visa and to others as determined by the Ministry of Health. Please contact the Ministry of Health directly if you are unsure.

    Are you, as the main applicant, aged 18 years or older? To be a policyholder you need to be 18 years or older.

    Your address

    Physical address

    Postal address

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    Information about your partner

    Would you like to add a partner to your application?

    Your partner's details

    Date of birth


    Information for each dependant child

    Would you like to add any children under 21 to your policy? Add a child

    Remove child


    Date of birth


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    Your declaration

    Please read carefully before agreeing. Failure to make this declaration truthfully may invalidate the policy.

    I apply for membership of the Southern Cross Medical Care Society ("Southern Cross") and agree to be bound by the Rules of Southern Cross.

    I hereby declare as follows:

    1. That the information I have disclosed is true and complete;
    2. That any further information I disclose to Southern Cross between the date I submit this application and the date I receive a Membership Certificate from Southern Cross is, at the time of disclosure, true and complete. I undertake to advise Southern Cross of any relevant information that may affect the policy, between the date I submit this application and the date I receive a Membership Certificate from Southern Cross.
    3. I accept the terms and conditions (including the limitations and exclusions) of the policy.
    4. I accept that certain benefits set out in the policy document have stand-down periods which means that I will be unable to claim for those benefits for a certain period after the policy start date.
    5. I understand that premiums may change with market variations and will change when any person named on this application enters a different age band.

    Financial strength rating

    Southern Cross Medical Care Society (trading as Southern Cross Health Society) has an A+(Strong)financial strength rating given by Standard & Poor's (Australia) Pty Limited.

    The rating scale is: AAA (Extremely Strong) AA (Very Strong) A (Strong)

    BBB (Good) BB (Marginal) B (Weak)

    CCC (Very Weak) CC (Extremely Weak) SD or D (Selective Default or Default)

    R (Regulatory Action) NR (Not Rated)

    Ratings from 'AA' to 'CCC' may be modified by the addition of a plus (+) or minus (-) sign to show relative standing within the major rating categories.
    Full details of the rating scale are available at Standard & Poor's is an approved rating agency under the Insurance (Prudential Supervision) Act 2010.

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    Payment options

    Payment method

    Are you the account holder with the authority to operate this account on your own?

    Account name

    Account number

    Confirm payment frequency

    Choose deduction The date your premium will be debited from your account.

    Confirm payment frequency

    Choose deduction The date your premium will be debited from your account.

    Conditions of authority to accept direct debits

    Here are the standard direct debit authority conditions. Please accept in the checkbox below.

    1. The Initiator (Southern Cross Medical Care Society):

    (a) Undertakes to give written notice to me/us of the commencement date, frequency and amount of the Direct Debit at least 10 calendar days (but no more than 2 calendar months) before the fi rst Direct Debit is drawn. Where the Direct Debit System is used for the collection of payments which are regular as to frequency, but variable as to amounts, the Initiator undertakes to provide me/us with a schedule detailing each payment amount and each payment date. In the event of any subsequent change to the frequency or amount of the Direct Debit, the Initiator has agreed to give written notice at least 30 days before that change comes into effect.

    (b) May, upon the relationship which gave rise to this Authority being terminated, give notice to the bank that no further Direct Debits are to be initiated under this Authority. Upon receipt of such notice, the Bank may terminate this Authority as to future payments by notice in writing to me/us.

    2. The Customer may:

    (a) At any time, terminate this authority as to future payment by giving written notice of termination to both the Bank and the Initiator.

    (b) Stop payment of any Direct Debit to be initiated under this authority by the Initiator by giving written notice to the Bank prior to the Direct Debit being paid by the Bank.

    (c) Where a variation to the amount agreed between the Initiator and the Customer from time to time to be direct debited has been made without notice being given in terms of clause 1(a) above, request the Bank to reverse or alter any such Direct Debit initiated by the Initiator by debiting the amount of the reversal or alteration of a Direct Debit back to the Initiator through the Initiator’s Bank, PROVIDED such a request is made not more than 120 days from the date when the Direct Debit was debited to his/her account.

    3. The Customer acknowledges that:

    (a) This Authority will remain in full force and effect in respect of all Direct Debits passed to my/our accounts in good faith, notwithstanding my/our death, bankruptcy or other revocation of this Authority until actual notice of such event is received by the Bank.

    (b) In any event this Authority is subject to any arrangement now or hereafter existing between me/us and the Bank in relation to my/our account.

    (c) Any dispute as to the correctness or validity of any amount debited to my/our account shall not be the concern of the Bank except in so far as the Direct Debit has not been paid in accordance with this Authority. Any other disputes lie between me/us and the Initiator.

    (d) The Bank accepts no responsibility or liability for the accuracy of the information about Direct Debits on Bank Statements.

    (e) The Bank is not responsible for, or under any liability in respect of:
    – any variations between notices given by the Initiator and the amounts of the Direct Debits on Bank Statements.
    – the Initiator’s failure to give written advance notice correctly, nor for the non receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation the dispute lies between me/us and the Initiator.

    (f) Notice given by the Initiator in terms of clause 1(a) to the debtor responsible for the payment shall be effective. Any communication necessary because of the debtor responsible for payment is a person other than me/us, is a matter between me/us and the debtor concerned.

    4. The Bank may:

    (a) In its absolute discretion conclusively determine the order of priority of payment by it of any monies pursuant to this or any other authority, cheque or draft properly executed by me/us and given to or drawn on the Bank.

    (b) At any time terminate this authority as to future payments by notice in writing to me/us.

    (c) Charge its current fees for the service in force from time to time.

    Conditions of authority to accept credit card

    Click here to view the terms and conditions.

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    Your application


    About you

    Fill out the form to register your details

    Gender: Male




    Physical address:

    Postal address:


    Staff number:

    Branch / department:

    Your family








    Policy starts on:

    Payment date:

    per week

    Contact us
    If you find any part of this application process difficult please:
    ● contact your sales representative or health insurance adviser
    ● call 0800 100 555 (8am - 5pm Monday-Friday); or
    ● email, and include a contact phone number if you wish.

    @ Southern Cross Medical Care Society