1. Congenital conditions and/or developmental disorders
2. Stomach, bowel, rectal or digestive disorders including haemorrhoids
3. Back pain, or any condition including neck/cervical, thoracic, lumbar and sacral spine
4. Bone, muscle or joint disorder, disease or injury including rheumatism or arthritis, gout and bunions
5. Heart disease or disorder including chest pain, angina, coronary artery disease, dysrhythmias, aneurysms, heart valve replacements or rheumatic fever
6. High blood pressure and/or high cholesterol
7. Blood or bleeding disorders including anaemia or B12 deficiency
8. Vascular or arterial disorders including varicose veins
9. Diabetes, thyroid or other glandular disorders
10. Liver or gall bladder disorders including hepatitis
11. Gynaecological or menstrual disorders including irregular, heavy or painful periods, any abnormal smears, or endometriosis
12. Eye disease including cataracts or glaucoma
13. Recurrent upper respiratory tract infections, adenoids, sore throat, ear infections, tonsillitis and sinusitis
14. Kidney or bladder disorders including stones, hernia, incontinence or pelvic floor disorder and prolapse
15. Suspicious moles, cysts, skin lesions, lipomas, including treatment for melanoma
16. Neurological or nerve conditions including migraines, epilepsy, paralysis or stroke
17. Cancerous and pre-cancerous conditions or tumours
18. Have any named applicants been advised that they may require any diagnostics, medical or surgical treatment in the future?
19. Have any named applicants suffered an accident or injury?
20. Have any named applicants taken in the past, or are currently taking, any medication on a regular basis?
21. Are any named applicants currently suffering from, or have suffered from in the past, any condition/ailment or received treatment not already disclosed?
Declaration
Applicant's Declaration
THIS DECLARATION IS VERY IMPORTANT. PLEASE ENSURE YOU READ IT CAREFULLY
1. I declare that all statements made for the purposes of this application to be true, correct and complete and that I have not omitted, and I am not aware, of
any other medical information or circumstances which might affect the risk of insurance on my health or that of any other person listed in my application. If, after submitting
this application, I become aware of any such medical information or circumstances, I agree to inform the Society immediately of such information or circumstances.
2. I acknowledge that failure to make any statements truthfully, or to omit any medical information or circumstances which might affect the risk of insurance on
my health or that of any other person listed in my application, may mean my application is rejected, or any claim made is declined, or the policy becoming void. I further
acknowledge that if this application is accepted by the Society, there is no cover for any health conditions I have not declared, but only for those conditions I have declared
which are accepted by the Society.
3. I understand that the written declaration in the Application Form constitutes the basis of the contract with the Society. No oral representation, inducement,
statements and promises made by or on behalf of either party, including the Sales Representative, and not contained in the Application Form or the brochure for the Health Plan
selected, shall be relied upon or binding.
4. Where other persons are listed in my application, I confirm that I have full authority and consent to submit this application on behalf of all such persons. I
understand that any statements made concerning such persons (or persons added to the policy at a later date) may affect whether this application is accepted or their entitlements
to cover.
5. I agree that any payment accompanying this application shall be a deposit only and I understand that any coverage will not commence until the Society has
issued a Membership Certificate. I further agree that the maintenance of membership and cover is conditional upon the continual payment of all premiums as they fall due.
6. I understand that any special joining concessions or restrictions of cover in relation to my declared existing conditions will be shown on my Membership
Certificate.
7. I authorise the obtaining of any medical information the Society may require in relation to this application or future claims as submitted by me from any
medical practitioner who has attended or examined me or any other person listed in my application. I agree to do anything necessary to facilitate the Society obtaining such
information, including completing or signing any necessary consents or authorities.
8. I authorise the Society to obtain details regarding my previous medical insurance.
9. Pursuant to the Privacy Act 1993 and the Health Information Privacy Code 1994 (incorporating amendments), in this application form the Society collects
personal information for the purpose of evaluating your membership application and future claims. The Society may disclose information related to this application and future
claims to the Integrity Register* for the purposes of the detection and prevention of fraudulent and suspicious conduct.
10. I agree to the terms and conditions of Membership and the rules of the Society.
11. If this application has been completed online, I acknowledge and agree that my electronic acceptance of this declaration (whether by electronic signature or
otherwise) makes it fully binding on me and any other persons listed in the application.
The Privacy Act 1993 requires UniMed to inform you about certain rights and
obligations relating to the information which we collect on this form. In this regard, we recommend that you read the Privacy Statement on our webpage https://www.unimed.co.nz/about-unimed/privacy-statement/
*The Integrity Register is a register of health insurance claims and administered by PwC (on behalf of HFANZ) for the purposes of the prevention and detection of fraudulent and
suspicious conduct.
