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Personal Details First Name: * Last Name: * APESMA Membership Number: * Date of Birth: * DD/MM/YYYY Spouse’s Date of Birth (if applicable): DD/MM/YYYY   Contact Details Postal Address: * Suburb: * State: * [State] ACT NSW NT QLD SA TAS VIC WA Postcode: *   Daytime Contact Phone (include area code): * Email: *   Existing Cover Details 1. Do you currently have health cover? * If you answered no to both, click here to go to Question 9   Hospital  Yes   No   |   Dental / Ancillaries (Extras) Yes   No 2. Type of Cover   Single   Couple   Family  Single Parent 3. Do you currently pay a Lifetime Health Cover loading on your Hospital Product?   Yes   No   Don't know 4. Name of current health fund: *   [Health Fund] AHM Australian Unity HBA HCF MBF Medibank Private Mutual Community NIB Other (please specify)   If Other, please specify 5. Name of product/s with fund:   Hospital Dental/Ancillaries (Extras) Hospital & Extras Package 6. What is your current premium?   $ per [Frequency] week fortnight month 6 months year 7. Does your current premium include the Federal Government Rebate?   Yes   No   Don't know 8. For same day hospital procedures, do you currently pay an excess or co-payment?   Yes   No   Don't know 9. Do you currently have ambulance cover? *   Yes   No   Cover Requirements 10. Which type of cover do you require? *   Hospital   Dental/Ancillary (Extras)   Both Hospital and Dental/Ancillary (Extras) 11. What type of cover do you require? *   Single   Couple   Family  Single Parent 12. What is your primary objective for taking out Private Health Insurance? Are you simply after a basic hospital policy? * (tick all that apply)   To avoid the Medicare Levy Surcharge To avoid Lifetime Health Cover Loading To gain peace of mind and to avoid waiting for elective surgeries To increase existing health insurance benefits To decrease premium of existing health insurance cover  Other (please specify) 13. Please indicate if you require any of the following HCF hospital services: (leave blank if you do not require Hospital Cover):   *Please note that all APESMA Health Hospital products automatically include 100% emergency Ambulance cover and 100% Accommodation cover in all public hospitals and HCF participating private hospitals. QLD & TAS residents are covered under their state ambulance scheme. Coronary Care Elective Cosmetic Surgery Maternity/Obstetrics Psychiatric Services Assisted Reproductive Services (i.e. IVF) Hip and Knee Joint Replacement surgery Cataract and other lens related surgery  Other (please specify, use commas to separate multiple entries)   Dialysis for Chronic Renal Failure 14. Please indicate if you require any of the following HCF Dental/Ancillaries (Extras) services: (leave blank if you do not require Extras Cover)   General Dental Optical Orthodontic Physiotherapy Oral Surgery (tooth extractions) Podiatry Endodontics (root canal therapy) Audiology Periodontics (gum treatment) Gym Programs (approved only) Crowns and Bridges Exercise Physiology Dentures Speech Pathology Chiropractic/Osteopathy Alexander Technique Remedial Massage/Acupuncture  Other (please specify, use commas to separate multiple entries)   Naturopathy/Homeopathy Dietary 15. Do you have any comments or queries?   16. Where did you find out about APESMA Health Insurance Assessment? *   Professional Network magazine Promotional email APESMA National e-News Browsing APESMA website Word-of-mouth Other (please specify)