I declare the information on this application to be true and correct. All terms and conditions are available by calling +613 8682 7000 or visiting australianunity.com.au/ovc-terms. I accept and agree to abide by the Overseas Visitor Health Cover Product Rules of Australian Unity Health Limited ABN 13 078 722 568, a summary of which is set out in the terms and conditions. I have read and understand the information contained in the product fact sheet and the member guide, including pre-existing conditions, waiting periods and benefit exclusions and restrictions. I authorise Australian Unity Health Limited to obtain from any previous fund, personal information about me or any others to be covered, for the purpose of continuity of health cover I also confirm that where this form contains personal information about other persons, I have obtained all necessary consents to disclose that information to Australian Unity Health Limited, and have the authority to act on those persons’ behalf. I authorise all such persons 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 for the purpose of processing this application, fulfilling Australian Unity's obligations in providing services to me, for the development of products and services, and to allow the Australian Unity Group to market products and services. By submitting this application form, I consent to the Australian Unity Group collecting and using this information for these purposes.

A copy of the Overseas Visitors Health Cover Product Rules can be provided to you by calling +613 8682 7000