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    GMHBA Cancellation Form

    Uploaded by

    jikolji
    This document is a cancellation form for a health insurance membership. It requests the member's name, number, email, address and contact details. It allows the member to choose to cancel their whole membership or a single person on the policy. It notes any pre-existing conditions or waiting periods that may apply if the member wishes to rejoin. It asks the member to provide the main reason for cancelling by selecting from options like cost, benefits not covered, or moving away.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    GMHBA Cancellation Form

    Uploaded by

    jikolji
    151 views1 page
    This document is a cancellation form for a health insurance membership. It requests the member's name, number, email, address and contact details. It allows the member to choose to cancel their whole membership or a single person on the policy. It notes any pre-existing conditions or waiting periods that may apply if the member wishes to rejoin. It asks the member to provide the main reason for cancelling by selecting from options like cost, benefits not covered, or moving away.

    Original Description:

    Form for cancelling insurance

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    © Attribution Non-Commercial (BY-NC)

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    This document is a cancellation form for a health insurance membership. It requests the member's name, number, email, address and contact details. It allows the member to choose to cancel their whole membership or a single person on the policy. It notes any pre-existing conditions or waiting periods that may apply if the member wishes to rejoin. It asks the member to provide the main reason for cancelling by selecting from options like cost, benefits not covered, or moving away.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    151 views1 page

    GMHBA Cancellation Form

    Uploaded by

    jikolji
    This document is a cancellation form for a health insurance membership. It requests the member's name, number, email, address and contact details. It allows the member to choose to cancel their whole membership or a single person on the policy. It notes any pre-existing conditions or waiting periods that may apply if the member wishes to rejoin. It asks the member to provide the main reason for cancelling by selecting from options like cost, benefits not covered, or moving away.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Cancellation Form

    Member name Member number Email address Address Suburb/city State Postcode Date Phone / /

    Cancel whole membership Cancel single person

    Yes

    No

    I hereby authorise cancellation of my membership with GMHBA Limited effective As I am transferring my membership to ailment/illness restrictions and waiting periods.

    Health Fund, I request that you issue to

    me a Clearance Certificate and claims history. I understand that should I wish to rejoin, I may be subject to pre-existing

    To help us improve our service to members, we would appreciate if you could provide the main reason for your decision to cancel. (Tick appropriate box) Consolidate cover Moved interstate/overseas Customer service Medicare Levy Surcharge Details Family changes Cost: service not covered Service not covered Provider contracts Product benefits Child dependant Other (list details below)

    Members signature

    Date

    GMHBA Limited gmhba.com.au 60-68 Moorabool Street, Geelong, Vic 3220 PO Box 761, Geelong, Vic 3220 Call 1300 446 422 Fax 03 5221 4582 Email service@gmhba.com.au ABN 98 004 417 092

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