HealthEssentials online application

Please accept the Southern Cross Privacy statement

We take your privacy seriously. Please read and tick the box to accept before you proceed.

1. I understand that:

the information Southern Cross collects in this application form and in the wider application process will be used to consider and process the application for health insurance and, if approved, consider the specific terms that apply to the policy, to administer the policy and for marketing purposes.
if any of the information requested as part of this application is not provided, it may delay the application being processed, or result in Southern Cross not providing the people named in this application with cover or associated benefits.
the people named in this application are entitled to have access to, and request correction of, any of their personal or health information held by Southern Cross.

2. I authorise Southern Cross to collect from, and to disclose to:

my husband/wife/partner (if named in this application form);
any person(s) nominated in writing by me;
third parties such as health services providers and medical authorities (including ACC and Ministry of Health), group administrators, agents, contractors, suppliers and other business partners;

information relating to people named in this application form and I authorise these parties to disclose to Southern Cross and receive from Southern Cross this information, in accordance with the Southern Cross Privacy Statement.

I authorise Southern Cross to collect information from a previous Southern Cross health insurance and/or Critical Illness policy (including previous application(s), membership certificate(s) and/or claims.)

3. In relation to any other people named in this application, I confirm that:

I am authorised to complete this application form on their behalf;
I am authorised to disclose to Southern Cross and to receive from Southern Cross their personal and health information and I have made each of them aware of the terms and conditions of Southern Cross’ full Privacy Statement (contained on Southern Cross’ website);
I have made each of them aware of the contents of this application; and
each of the people named have authorised me to give the acknowledgements, undertakings and authorities set out above on their behalf.

Management of this and other personal and health information provided to Southern Cross is subject to the terms of the full Southern Cross Member Privacy Statement. View the up-to-date copy of the full Southern Cross Member Privacy Statement or contact Member Services on 0800 800 181.

I agree to the Southern Cross Medical Care Application Privacy Statement

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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

Salutation

Name

Date of birth

Gender

Male Female

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

I am an employee of

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Eligibility

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.

Yes No

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.

Yes No

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

Yes No

Your address

Physical address

Find your address

Or enter your address manually

Is your postal address different from your physical address?

Postal address

Find your address

Or enter your address manually

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Information about your partner

Would you like to add a partner to your application?

Yes No

Your partner's details

Date of birth

Gender

Male Female

Information for each dependant child

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

Remove child

child

Date of birth

Gender

Male Female

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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:

That the information I have disclosed is true and complete;
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.
I accept the terms and conditions (including the limitations and exclusions) of the policy.
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.
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 www.standardandpoors.com. Standard & Poor's is an approved rating agency under the Insurance (Prudential Supervision) Act 2010.

I have read, understood and hereby agree as set out above.

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Payment options

Payment method

Credit card

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

Yes No

Account name

Account number

Please provide a valid bank account number.

Confirm payment frequency

Weekly Fortnightly Monthly

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

Confirm payment frequency

Monthly

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.

Conditions of authority to accept credit card

Click here to view the terms and conditions.

If your application is accepted, you authorise Southern Cross Medical Care Society ('Southern Cross') until further notice in writing to charge your credit card with all the amounts (in New Zealand dollars) due on your Southern Cross account from time to time, on or after the payment due date.

Your credit card will be charged on the payment date you have chosen . We'll give you at least 10 days written notice prior to your first payment, by sending you an invoice / statement . To help us, please ensure you submit this authority at least 15 days before your first payment is due. If we don't receive this from you in time or if we're unable to process your request in time, your first payment may occur on another payment date determined by us and the first payment may include more than one billing period. If you were previously paying by credit card your payment date won't change.

We will automatically adjust the payment amount when changes happen to your policy and notify you in advance of the payment date and amount. You may terminate this authority for future payments by giving us formal notice. Where a request to terminate has been received, we will try to cancel future payments as soon as we can but there may be circumstances where we are unable to do this until after the next scheduled payment.

You're responsible for updating your credit card details when you change credit card issuers or receive a replacement credit card with a new card number. Please do this online at mysoutherncross.co.nz and go to My billing and payments. You can also visit southerncross.co.nz/society/for-members/policy-membership/payment or contact us on 0800 800 181 to get a new authority form.

Southern Cross is committed to data security and uses a variety of technologies and procedures to help protect personal information from unauthorised access, use or disclosure. Web portals use Encryption such as secure socket layer (SSL) protocol. Southern Cross does not process or store credit card details but uses a third-party trusted vendor, Payment Express, to process all credit card purchases. Payment Express is a level 1 certified PCI-DSS compliant provider.

Southern Cross Medical Care Society operates from New Zealand (Level 1, Ernst & Young Building, 2 Takutai Square, Auckland 1010, New Zealand).

I accept the conditions of authority to accept direct debits.

I agree to set up recurring credit card payments in accordance with the terms and conditions.

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Let’s just check we’ve got this right…

Your application summary

Cover

Employment

Staff number:

Branch / department:

About you

Gender: Male

DOB:

Mobile:

Email:

Physical Address:

Postal address:

Your family

Gender:

DOB:

Gender:

DOB:

Payment

Frequency:

Policy starts on:

Payment date:

per week

Please enter the code shown below exactly as it appears. This field is case-sensitive.

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Your application

Cover

About you

Fill out the form to register your details

Gender: Male

DOB:

Mobile:

Email:

Physical address:

Postal address:

Employment

Staff number:

Branch / department:

Your family

Gender:

DOB:

Gender:

DOB:

Payment

Frequency:

Policy starts on:

Payment date:

per week

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 Help@Southerncross.co.nz, and include a contact phone number if you wish.