I confirm the information I have provided is true and correct.
I understand that this product only provides cover for individuals when in Australia on particular working visas.
By providing my bank account details, I agree to the direct debit facility and authorise Immsure Insurance to debit my nominated bank account. I understand that Immsure Insurance will debit my account, and both I and Immsure Insurance will be bound by the terms and conditions set out in the Direct Debit Service Agreement.
I acknowledge and agree to the Fund Rules, Member Guide, and Product Fact Sheet that apply to this insurance policy (as updated from time to time).
I agree to Immsure Insurance collecting, using, and disclosing my personal information for the purposes of providing this insurance policy and services in connection with it. I also agree to Immsure Insurance protecting my personal information in accordance with Australian privacy laws and as described in its Privacy Policy (as updated from time to time).
Your agent in Australia, Liberties Insurance, is assisting you to acquire a private health insurance policy issued by AIA Health Insurance Pty Ltd.
So that AIA Health Insurance can issue a private health insurance policy to you, please confirm that you:
• have appointed Liberties Insurance to act on your behalf to arrange for a private health insurance policy with AIA Health Insurance to be issued to you in your name. This insurance policy will only provide cover for you when you are in Australia and are on a particular working visa. It will not provide cover to your partner, spouse, children or other family members unless AIA Health Insurance separately agrees to update your policy.
• agree that Liberties Insurance can provide AIA Health Insurance with your personal information for the purposes of issuing and managing your policy. This will include providing AIA Health Insurance with your full name, date of birth, visa type, country of nationality, gender, email address, country of residence, mobile phone number, address while in Australia, the expected start date for your insurance policy and your expected visa end date.
• consent to AIA Health Insurance collecting, using and disclosing (including to Liberties Insurance) your personal information for the purpose of providing your insurance policy and services in connection with it, and consent to AIA Health Insurance protecting your personal information in accordance with Australian privacy laws and in the manner described in its Privacy Policy (available at https://health.aia.com.au/international/overseas-visitors-health-cover, as updated from time to time).
• agree that Liberties Insurance can arrange for your premium (the cost of your insurance policy) to be paid to AIA Health Insurance. If Liberties Insurance ceases to be your agent and if you are still eligible to keep your insurance policy (for example, because you remain on the same visa), you must:
o contact AIA Health Insurance directly to notify them that Liberties Insurance is no longer your agent; and
o pay your premium directly to AIA Health Insurance to keep your insurance policy active. • Agree that you must contact AIA Health Insurance directly and not through Liberties Insurance if:
o you wish to make any changes to your insurance policy (including but not limited to making changes to your personal details); and/or
o you wish to terminate your insurance policy.
• have received and agree to the Fund Rules, Member Guide and Product Fact Sheet that apply to my insurance policy.