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
Check the MFAT Foreign Country Travel Safety Reports BEFORE you travel overseas.
If your travel itinerary ignores HIGH or EXTREME RISK country safety warnings there may be no cover under your policy for events that arise that were the subject of such warnings.
APPLICANT DETAILS
Enter Titles, Names and Dates of Birth of insured persons:-
Country of Origin
Main contact address - Place each part of the address on a new line. Main contact telephone
Main contact fax
Email address for Upgrade Certificate of Insurance Must be a working email address. Hotmail users please check your junk box.
Main Uni-Care policy number Enter "Pending" if main policy is not yet issued.
Main Uni-Care plan Select Plan NZ Student NZ Visitor Australasian
Select Plan NZ Student to NZ Visitor Plan NZ Student to Australasian Plan NZ Student to Outbound Plan A NZ Student to Outbound Plan B ------------ NZ Visitor to Australasian Plan NZ Visitor to Outbound Plan A NZ Visitor to Outbound Plan B ------------ Australasian to Outbound Plan A Australasian to Outbound Plan B Australasian Plan: Cover for Australia & New Zealand, plus visits to the South Pacific Islands, Bali & Lombok Outbound Plan A: Worldwide cover including Continental Europe, The USA, Hawaii, Canada & Japan Outbound Plan B: Worldwide cover excluding Continental Europe, The USA, Hawaii, Canada & Japan
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.
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 11 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 1. Check the MFAT Foreign Country Travel Safety Reports and your itinerary before you submit this application. 2. If you wish to keep a copy of your online application form or retain a record of the calculated premium, print this form out now.
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.
