First Name*

Last Name*

Email*

Your NZFFWS Membership Number*

Date of Birth*

Your Phone Number*

Select which option you would like to join
Option AOption B

Address*

Your Postcode

Bank Account Number for Reimbursements*

Partner/Spouse
First Name

Last Name

Date of Birth

Child #1 Name
First Name

Last Name

Date of Birth

Child #2 Name
First Name

Last Name

Date of Birth

Child #3 Name
First Name

Last Name

Date of Birth

Child #4 Name
First Name

Last Name

Date of Birth

DECLARATION
List pre-existing and congenital conditions below

First Name

Last Name

Condition

Date of Last Symptoms

Treatment Description

First Name

Last Name

Condition

Date of Last Symptoms

Treatment Description

First Name

Last Name

Condition

Date of Last Symptoms

Treatment Description

I/We declare that:

• ​I/We agree that the quotation shall be the basis of the contract between myself/us and Healthcare 99 and I/We am/are willing to accept the terms, conditions and exclusions of Healthcare 99.
• The answers and information given and on any attachment are in every respect correct.
• I/We authorise the disclosure of personal information held by any party regarding any claim regarding my/our existing ​or previous insurances.
• I/We agree to Healthcare 99 releasing to other parties personal information regarding any claim.

​Have you or any other person to be covered under this Healthcare 99 Benefit ever had any insurer decline, cancel, require withdrawal, or ever have imposed special terms on you or ever refused you a claim?

Yes or No
NoYes

Is there any further information that may affect the acceptance of membership to Healthcare 99 (eg. bankruptcy, insolvency, criminal activity or associations or convictions or any other circumstances giving greater than normal risk of loss. Note this is not an exhaustive list)

Yes or No
No - I have nothing further that may affect this applicationYes - I have more information to declare

I understand that on being approved for membership, I will accept the Rules of the Society as being binding upon me. I hereby give authority for the Society to have deducted from my wages, salary or other payments as the case may be, the contributions payable to the Society and any levies which may from time to time be imposed and subsequently ratified at the Annual General Meeting of the Welfare Society. I will not be a full member until my first contribution fee has been received by the office of the Welfare Society. Once this form is submitted, if I do not have a payroll number I will receive a direct debit form from the office which I will complete and return to the office of the Welfare Society so my full membership can be confirmed.

Tick this box to agree*
I agree and understand Healthcare99 is a mutual fund and not an insurance