I declare and acknowledge that:

1. The information provided in this form is true, complete and correct.
2. I have read and understood the information contained in the CBHS Corporate Health Product Brochure which includes important information about limits, pre-existing conditions, waiting periods (including 12 months for pre-existing conditions), inclusions, exclusions and restrictions which apply to my chosen level of cover.
3. I accept and agree to be bound by the Health Benefit Fund Rules of CBHS Corporate Health which can be accessed on the CBHS Corporate Health website at www.cbhscorporatehealth.com.au or by calling +61 2 8604 3537 and understand this may mean my contribution rates are increased or my benefit entitlements are changed.
4. If I cancel my CBHS Corporate Overseas Visitors Health policy prior to or within 30 days of the commencement date of my cover, I authorise CBHS Corporate Health to charge an administration fee equal to my contribution rates payable for 30 days.
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5. I am the policy holder who is responsible for payment of the contribution rates and the receipt of all CBHS Corporate Health policy correspondence.
6. I have read and understood the Privacy Collection Notice below and the CBHS Corporate Health Privacy Policy which can be accessed on the CBHS Corporate Health website at www.cbhscorporatehealth.com.au or by calling +61 2 8604 3537.
7. I consent, and am authorised by each person listed in this application form to consent, to the collection, use and disclosure of personal and health information for the purposes summarised in the Privacy Collection Notice and identified in the CBHS Corporate Health Privacy Policy.
8. This authority replaces all previous authorities and remains valid until written notification is given by either me or CBHS Corporate Health.
9. I authorise CBHS Corporate Health to terminate my membership with my previous health insurer (if still current) and/or obtain details about my membership, including benefit payments and/or refund any contribution paid beyond the date my CBHS Corporate cover commences.

Termination within six months

1. If I receive any waiver or reduction of Waiting Periods and cease to be a member of CBHS Corporate Health and in the immediately preceding 6 months incur an expense and receive a Benefit for artificial aids, health care appliances, oxygen and related apparatus, optical appliances, orthodontics or crowns or bridges, CBHS Corporate Health may require me to reimburse CBHS Corporate Health for that part (if any) of the Benefit which would not have been paid, had the waiver or reduction been applied. For more details, refer to the Health Benefit Fund Rules of CBHS Corporate Health which can be accessed on the CBHS Corporate Health website at www.cbhscorporatehealth.com.au or by calling +61 2 8604 3537.

Privacy Collection Notice

1. CBHS Corporate Health collects your personal and health information including sensitive information to provide you with its health insurance products and services, including for the payment of benefits and product development purposes, and to communicate with you in relation to specialised health programs and offers from CBHS Corporate Health.
2. Personal and health information may be collected from you directly when you tell us or complete a form, or indirectly, for example, by way of cookies when you visit the CBHS Corporate Health website.
3. By providing your personal and health information you consent to its collection, use and disclosure by, CBHS Corporate Health under the terms of this Privacy Collection Notice and the CBHS Corporate Health Privacy Policy which contains information about how you may access and seek to correct your personal and health information or complain about a breach of the Australian Privacy Principles, and how CBHS Corporate Health will deal with that complaint.
4. CBHS Corporate Health may disclose your personal and health information to entities such as hospitals and medical providers and personal information to third party service providers such as data storage and data handling providers. Such disclosure will only be made in a way which is consistent with the CBHS Corporate Health Privacy Policy.
5. CBHS Corporate Health may contact you (by phone, email, SMS or post) and use and disclose your personal information for direct marketing purposes, unless you opt out (which you can do at any time in accordance with the CBHS Corporate Health Privacy Policy).

I have read, understood and accept the Declaration, Termination within 6 months and Privacy Collection Notice