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Complete your details, and we will contact you to discuss your health insurance needs, and answer any questions.

I would like to talk about health insurance for

Name * Title First Name Surname

Email Address *

Date of Birth * Day Month Year

Gender

Address * Street Address Suburb Town/City

Daytime Phone * Alternative Phone Contact me via

Eligibility to work in New Zealand

Are you a New Zealand or Australian citizen or do you hold a resident visa or a work visa valid for at least 2 years?*

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Comments

How did you hear about us?

If your employer offers Southern Cross health insurance you could be entitled to extra benefits.

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Branch Address (Suburb)*

Email Privacy – Application Declaration

The personal information you provide by email via our site is received, collected and held by Southern Cross Medical Care Society, at 181 Grafton Road, Auckland.  You have the right of access to, and correction of, this personal information held by Southern Cross in accordance with the provisions of the Privacy Act 1993.

The information is required for a number of different purposes. 
- It will be used for administration purposes; 
- It will be used to enable us to contact you via email, telephone or letter for the purposes as requested by yourself; and
- finally, the personal information may also be used for statistical purposes, but for this purpose you will not be identified, nor will any of the other people who may be included in the email.

If you decide to make an application to Southern Cross:

1.  I understand that:

(a)  the information Southern Cross collects in this application will be used: 
- to consider the eligibility for cover of people named in this application;
- to consider the specific terms applying to the policy and any associated benefits (including the exclusion of cover for any pre existing conditions); 
- for administration purposes such as billing and claims management; and 
- for marketing purposes.

(b)  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.

(c)  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); 
- 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 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.

In relation to any other people named in this application, I confirm that:
- I am authorised to complete this application on their behalf; 
- I am authorised to disclose to Southern Cross and to receive from Southern Cross their personal and health information; 
- 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 at (1) and (2) above on their behalf.

Management of this and other personal and health information provided to Southern Cross is subject to the terms of the Southern Cross Privacy Statement. For an up to date copy of the full Southern Cross Privacy Statement, please refer to your Policy Document, visit our website at www.southerncross.co.nz or contact our Member Services Centre on  0800 800 181.

I confirm that I have read and agree to the terms of the Email Privacy
– Application Declaration and the terms of use.*