Change to Membership Details Request

Member name *

Membership number *

I wish to change *

My contact details

My Union Health cover

Adding or removing a person on my membership

Change surname on my membership

Contact details

Complete only if any details have changed (if you’re not sure, please provide your current details).

Address

State

Postcode

Home phone

Work phone

Mobile phone

Email address

Communication preference

Email

Mail

My cover is for

Type/Scale

If you require extended dependant cover, please select this option in addition to the single parent cover or family cover options. This option is available on all open hospital covers except Gold Hospital.

Cover type

Please select the cover required. Please refer to the product brochure(s) and the Important Information Guide before completing this section. Excess is per adult, per calendar year.

Hospital cover with excess

Extras cover *

Persons affected

Person 1

Given name

Surname

Date of birth

Day

Month

Year

Relationship

Please select where applicable

Add to membership

Remove from membership

Request membership card

If applicable, previous health fund name

If deceased, provide date of death

Day

Month

Year

Person 2

Given name

Surname

Date of birth

Day

Month

Year

Relationship

Please select where applicable

Add to membership

Remove from membership

Request membership card

If applicable, previous health fund name

If deceased, provide date of death

Day

Month

Year

Person 3

Given name

Surname

Date of birth

Day

Month

Year

Relationship

Please select where applicable

Add to membership

Remove from membership

Request membership card

If applicable, previous health fund name

If deceased, provide date of death

Day

Month

Year

Person 4

Given name

Surname

Date of birth

Day

Month

Year

Relationship

Please select where applicable

Add to membership

Remove from membership

Request membership card

If applicable, previous health fund name

If deceased, provide date of death

Day

Month

Year

Surname change

Please note: If you are wanting to change a first name for a member on the policy, we will require evidence to action that request. Please send us an email (with attached evidence) to enquiries@tuh.com.au

Current surname (as recorded on membership)

New surname

Date of birth

Day

Month

Year

Date effective from

Immediately when my request has been accepted (An initial payment and/or an adjustment premium may be required at a later date)

Nominate a date in the future

Nominated date

Day

Month

Year

Declaration

I declare that:

• The information I’ve provided in this request is correct and complete;

• I agree to be bound by the Fund Rules and Constitution of 'TUH (Union Health)' as amended from time to time;

• I understand that any changes to my cover may change my premiums;

• I have had the opportunity to read the Important Information Guide and the product brochure for my cover;

• I understand the terms and conditions of my cover, including the benefit entitlements, waiting periods, pre-existing conditions rules, exclusions, restrictions and excesses that may apply;

• I am aware that details of Union Health's privacy policy are available here and I consent to Union Health collecting, using and/or disclosing my personal information for the purposes stated in the policy;

• (If applicable) I am authorised to act on behalf of my partner and/or dependants that I have named in this request; and

• I am aware that I have a 30 day cooling-off period that commences from the change of cover date.

I have read and agree to the above declaration *

Yes

Change to Membership Details Request Form