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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Please advise Uni-Care if you are engaged in long term employment or permanently residing in an overseas country.
Check the MFAT Foreign Country Travel Safety Reports BEFORE you apply for travel insurance.
If your travel itinerary ignores HIGH or EXTREME RISK country safety warningsthere may be no cover under your policy for events that arise that were the subject of such warnings, nor for additional costs of, belatedly, choosing to act upon MFAT warnings that had earlier been available to you.
Applications cannot be processed until payment has been received. This is a secure site and the information you submit is encrypted for your security.
INFORMATION
This application form applies only to New Zealand Permanent Residents travelling overseas. It does not apply to International Students and Visitors to New Zealand and Australia. Students or visitors currently insured with Uni-Care, who wish to travel out of New Zealand or Australia, should go to Inbound Upgrades.
You are covered for stopovers in higher risk/cost countries en-route from and to New Zealand to a maximum of 9 days each way. If you intend to spend a longer period of time in transit than 9 days you are required to upgrade to an appropriate plan for the risk region you are travelling through. (For example: spending time in the USA would require Plan A whereas Thailand would require Plan B). Please refer to the Destination Exclusions for a list of countries which are not covered.
You can upgrade your policy to cover: 1. Short-term excursions to higher risk/cost countries during the period of insurance. 2. Extended visits to higher risk/cost countries enroute to and from New Zealand. To do this, go to the Outbound Upgrades section of this website after you complete this application form.
ESSENTIAL QUESTIONS
1. Are you a NZ citizen or entitled to Permanent Residency? Yes No
2. Have you ever been declined insurance or had special terms imposed? Yes No
3. Where are you applying from? New Zealand Other Country
Date of departure from New Zealand 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2012 2013 2014 2015 2016 2017 Date of return to New Zealand 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2012 2013 2014 2015 2016 2017
Date of departure from New Zealand 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2012 2013 2014 2015 2016 2017
Date of return to New Zealand 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2012 2013 2014 2015 2016 2017
4. Have you had insurance with Uni-care before? Yes No
5. If you are not applying from New Zealand, have you been insured for your travel to date? Yes No
If Yes: (i) please provide your current policy number. (ii) please state the date on which your travel insurance will (or has) expire(d). (iii) please indicate which insurance category your current insurance policy falls under. Please select Travel & Medical Medical Travel Accident Free with credit card
Very Important Information: (A) Uni-Care strongly recommends that travellers insure prior to the commencement of their travel and maintain continuity of cover. You may apply for a maximum of 550 days (18 months) cover at one time. Underwriter approval would be required to extend the period of cover beyond two years. (B) If you are travelling to reside permanently overseas or reside and work overseas long term then you would require an EXPATRIATE insurance policy. We can help in that regard but, at present, cannot offer such a policy.
APPLICANT DETAILS
Enter Titles, Names and Dates of Birth of applicants:- If Dates of Birth are not entered the policy can not be issued.
FAMILY DEFINITION: Family means You and/or Your Spouse and Your financially dependant children and legal wards 18 years of age and under who remain in Your full custody and control during the trip. Husband and wife or partners travelling together are advised to apply for individual policies.
Destination(s)
Main contact address in New Zealand - Place each part of the address on a new line. Main contact telephone in New Zealand
Email address Must be active account for receipt of official Certificate of Insurance. Hotmail users please check your junk box.
Email address for Renewal Notices Sent only if policies are for 6 months or longer.
Union/Association (Please select one of the following organisations so that we can allocate support funding.) Please select AUSNZ NZPPTA NZEI TIASA PSA NZNO ASTE None
PERIOD OF INSURANCE
SELECTION OF COVER Will calculate up to 550 days (18 months). Please refer to the Destination Exclusions for a list of countries which are not covered. Plan A - for travel to the USA, Canada, Japan & Continental Europe Plan B - for travel to the United Kingdom and the rest of the world, excluding countries specified under Plan A Plan C - for travel to Australia and the South Pacific Islands, Bali & Lombok
SPECIFIED 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.) Lesser valued items of luggage are covered under the general luggage allowance.
Click again if you alter any of the selections.
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
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 New Zealand, 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 accept that failure to supply correct application and medical certificate details may affect the validity of the policy.
7. You have certain rights of access to and correction of this information.
8. You understand that this policy does not cover any event, which happens to you unless you, at the date of such event, are aged 80 years or under.
9. 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.
10. 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.
11. 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 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.