I declare the information in this application to be true and correct. I accept and agree to abide by the health benefit fund rules of Australian Unity Health Limited ABN 13 078 722 568, a summary of which is set out in the terms and conditions.

Australian Unity Health Limited members may be eligible to become a member of Australian Unity Limited after completing 2 years of continuous membership. By applying to become a member of the Health Fund, I acknowledge that I am also applying to become a member of Australian Unity Limited, and I agree to abide by its rules.

I also confirm that where this form contains personal information about other people, I have obtained all necessary consents to disclose that information to Australian Unity Health Limited, and have the authority to act on their behalf. I authorise all members covered by this policy to make claims under my health cover as per the terms and conditions.

I understand that this application does not become effective until Australian Unity accepts this application and I am notified in writing.

I acknowledge that the personal information Australian Unity collects from me is collected in accordance with their Privacy Policy for the purpose of processing this application and fulfilling Australian Unity's obligations in providing services to me. I also consent to the Australian Unity Group using this information as outlined in the Policy for the development of products and services, and to market those products and services to me.