Uni-Care International Travel Insurance Service Crombie Lockwood (NZ) Limited Level 5, 33 Enfield Street, Mt Eden, Auckland 1024 PO Box 68910, Newton, Auckland 1145, New Zealand Telephone: +64 9 623 9890 Email: insure@uni-care.org
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COMPLETE IN ENGLISH
APPLICANT DETAILS
Enter Titles, Names and Dates of Birth of applicants:- If Dates of Birth are not entered the policy can not be issued.
Do you have or have you applied for New Zealand or Australian residency status? Yes No.
Have you been working or will you be working in New Zealand or Australia for 2 years or longer? Yes No.
Country of Origin -- Please select a country-- AlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBermudaBosnia & HerzegovinaBotswanaBrazilBruneiBulgariaCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandColombiaCook IslandsCosta RicaCroatiaCuracaoCyprusCzech RepublicDenmarkDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGuineaHaitiHawaiiHondurasHong KongHungaryIcelandIndiaIndonesiaIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMexicoMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNambiaNauruNepalNetherland AntillesNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorwayOmanPakistanPalau IslandPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPohnpei MicronesiaPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSaipanSamoaSamoa AmericanSan MarinoSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)Slovak RepublicSolomon IslandsSouth AfricaSpainSri LankaSt Vincent & GrenadinesSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandTahitiTaiwanTajikistanTanzaniaThailandTimor-LesteTogolese RepublicTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnion of MyanmarUnion of the ComorosUnited Arab EmiratesUnited KingdomUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (Brit)Virgin Islands (USA)Wallis and Futuna IslandsYemenZaireZambiaZimbabwe (Country of Origin is that country outside New Zealand in which You have established permanent residency and is where Your Travel commenced)
Main contact address - Place each part of the address on a new line.
Email address for Certificate of Insurance Must be a working email address that accepts attachments. Hotmail users please check your junk box.
Main contact telephone
Have you had insurance with Uni-care before? Yes No
Are you currently insured or have you been insured whilst in New Zealand? Yes No
If yes - Name of insurer Other insurance expiry date Current policy number
Have you ever been declined insurance or had special terms imposed? Yes No
Are you applying from New Zealand? Yes No
EDUCATIONAL INSTITUTION INFORMATION (for NZ Student plan only)
NZ University students select your university Select from list Auckland University of Technology Lincoln University Massey University - Albany Massey University - Palmerston North Massey University - Wellington University of Auckland University of Canterbury University of Otago University of Waikato Victoria University
Other students enter name of educational institution
PERIOD OF INSURANCE
SELECTION OF COVER The NZ Student plan can be purchased by international students studying in New Zealand and will provide cover in transit for a maximum period of 9 days each way. If you remain in New Zealand after the period of study or travel, or move to Australia you must upgrade to the NZ Visitor plan or the Australasian plan. The NZ Visitor plan can be purchased by visitors to New Zealand and will provide cover in transit for a maximum period of 9 days each way. The Australasian plan is for visitors to Australia and New Zealand (Australasia). This plan applies to any travel within the region and will provide cover for a maximum of 9 days in transit to and from this region. NOTE! If you are to be in transit for more than 9 days, you must apply for an upgrade to your original plan.
SPECIFIED VALUABLE ITEMS COVER The policy limit for any one item, set or pair of items is $2,500 unless the item, set or pair of items is specified and additional premium is paid. (Additional premium will be charged at a rate of 2% of the full value of the item.)
MEDICAL DECLARATION
Please answer the following questions:
Full information must be provided below if you have answered 'Yes' to any of the above questions otherwise proceed to the next section of the application.
Details of Medical Condition(s): Please enter persons name and full description of medical conditions giving details of treatment, medication and whether the condition is stable or unstable.
Name and address of doctor or specialist:
Doctor telephone Doctor fax
Personal notes relating to your application
DECLARATION (Please read carefully)
1. You have not been refused Travel Insurance by any other company nor are you insuring with the intention of receiving medical treatment or to claim for events which have already occurred.
2. You are not aware of any circumstances likely to lead to cancellation or curtailment of the trip. The underwriter is aware of all facts likely to affect the acceptance or conditions of this insurance. You will notify the underwriter of changes in circumstances or health occurring prior to your commencement date.
3. You confirm details have been correctly declared in this application form including the Medical Certificate incorporated in this document to be submitted for approval by the underwriter.
4. You agree, in the event of illness or injury giving rise to claims under the medical section of the policy, to be medically evacuated to Australia, New Zealand or your Country of Origin, as applicable, at the underwriters discretion.
5. You have read and understood our Privacy Policy and you agree to a waiver of privacy in that you consent to any requested medical information being released by your doctor, specialist, or other health provider to the Underwriter or its agent and to the release of any further information necessary for the purposes of this insurance. Click here to view our Privacy Policy
6. You authorise any claim to be paid to any named institution which has submitted claim details and requested payment to be made to them on your behalf.
7. You accept that failure to supply correct application and medical certificate details may affect the validity of the policy.
8. You have certain rights of access to and correction of this information.
9. You understand that this policy does not cover any event, which happens to you unless you, at the date of such event, are aged 65 years or under.
10. You understand and agree that the act of transmitting this application to Uni-Care, by activating the 'Submit Application' button on the web application form, will have the legal force of a signature, will implement an application for insurance and will authorise Uni-Care to deduct the premium from the credit card detailed above (or invoice an educational institution if appropriate and agreed by us).
11. I understand that the Policy Wording and Benefits Payable displayed in this website today are those applicable to the policy I am purchasing today, and may have changed since I held a previous policy.
12. You have read and understood and accepted the above statements and accept responsibility for all the information provided in this application.
Declaration Box - The Declaration Box must be clicked in order for your application to be submitted. APPLICANT STATEMENT: I have clicked in the Declaration Box as proof of the fact that I have read, agree and accept paragraphs 1 to 12 of the Declaration which is a compulsory element of the Uni-Care on-line application form.
PAYMENT DETAILS Applications cannot be processed until payment has been received.
Please select one of the following payment options. Direct Credit payments must be done immediately you receive our bank account details by return email.
IMPORTANT If you wish to keep a copy of your online application form or retain a record of the calculated premium, print it out NOW. Details from online applications are imported directly into our database and will not be available again in the original format.
Click on this button only once. There may be several seconds delay before an acknowledgement appears. If you click twice we receive two application transmissions. We remind you that a correct working email address is essential for our confirmation.