Tell Us About Yourself

Enter your details as the policyholder.

Person 1

Primary policyholder Relationship

Email address

First name

Last name

Sex at birth

Date of birth

Add Your Family To Your Policy

It is optional to add your family to your policy. Adding your family may come with a cost. You can see the estimated cost when you view the quotes generated in the next step.

Confirm residency status
Are you and all family members named in this application New Zealand citizens, holders of a resident visa or holders of a work visa for a minimum of two years or otherwise entitled to free public healthcare for all services as determined by the Ministry of Health? If not, please do not proceed. Contact your UniMed Representative or UniMed Head Office on 0800 600 666.

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3
Review & Payment

Review your selections

Complete payment authority

Enter your Direct Debit details for the bank account you would like to use. Please ensure you have reviewed your selections, the total amount, and the frequency of payments.

First name

Last name

Bank name

Account name

Bank account number

Preferred deduction date

Conditions of this authority to accept direct debit

Expand for full conditions

The Initiator
1. Has agreed to give advance Notice of the net amount of each direct debit and the due date of debiting at least 10 calendar days before (but not more than 2 calendar months) the date the direct debit will be initiated. This notice will be provided either:
  1. in writing; or
  2. by electronic mail where the Customer has provided prior written consent to the Initiator The advance notice will include the following message: “Unless advice to the contrary is received from you by (*date), the amount of $..... will be directly debited to our Bank account on (initiating date).” * This date will be at least two days prior to the due date to allow for amendment of direct debits
2. 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 the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future payments by notice in writing to me/us.
The Customer may:
1. (a) At any time, terminate this Authority as to future payments by giving written notice of termination to the Bank and to 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.
The Customer acknowledges that:
1. This authority will remain in full force and effect in respect of all direct debits made from me/our account 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.
2. 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.
3. Any dispute as to the correctness or validity of an 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.
4. Where the Bank has used reasonable care and skill in acting in accordance with this authority, the Bank accepts no responsibility or liability in respect of:
  1. the accuracy of information about Direct Debits on Bank statements
  2. any variations between notices given by the Initiator and the amounts of Direct Debits
5. The Bank is not responsible for, or under any liability in respect of 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.
The Bank may:
1. 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.
2. At any time terminate this authority as to future payments by notice in writing to me/us.
3. Charge its current fees for this service in force from time-to-time.

I/We authorise you until further notice, to debit my/our account with all amounts which Union Medical Benefits Society Limited (hereinafter referred to as the Initiator) the registered Initiator of the above Authorisation Code, may initiate by Direct Debit. I/We acknowledge and accept that the bank accepts this authority only upon the conditions listed above.

The Privacy Act 2020 provides you with certain rights relating to the information which we collect in this application. We recommend that you review our Privacy Statement prior to submitting this claim.

Before you submit: Please make sure all questions have been answered honestly and completely. If you have not provided complete or accurate information your application may be delayed or may not be progressed. Providing inaccurate or incomplete information may result in any future claim being delayed or declined. Information that is false or misleading may also affect the rights to your ongoing membership with UniMed.

In order to assess and process your application (or any future changes or claims) we may need to share or obtain further information on any person listed in this form from other parties, such as any treatment provider or your GP. All information collected will be used and protected in accordance with UniMed’s privacy statement.

I understand and agree to the above conditions.

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Protecting your privacy

This is a secure online portal for you to easily review and manage your UniMed health insurance plan. Any information you submit through this portal will be accessed and used by UniMed for the purposes of administering your health insurance plan. You can read UniMed's Privacy Statement in full at unimed.co.nz.

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