Active Reservist Declaration
Member ID Date of Birth
Member Surname Member First Name
Daytime Phone Email
RESERVIST DETAILS
Commenced as Reservist Service RANR ARES AFRES
PAYMENT METHOD
Tick here if currently and wanting to continue paying premiums via monthly direct debit from your nominated bank account or credit card.
Alternatively, to arrange a monthly direct debit from a different account or credit card, please complete one of the following methods.
1) Credit Card Visa Mastercard
To protect your privacy Navy Health does not request credit card information to be written on this form. If you would prefer to pay your premiums with a credit
card, please tick the box above and we will contact you regarding your ongoing credit card payment once your Reservist Declaration has been accepted.
2) Direct Debit Request
Financial Institution
BSB Number Account Name
Account Number
I/we request Navy Health (Id. No 25776) to debit funds from my/our nominated account according to the details specified above through the Electronic Banking System. This authorisation is to remain in
force in accordance with the terms described in the Direct Debit Service Agreement (available at www.navyhealth.com.au). I/we request that you debit the appropriate amount, at the payment frequency
specified. The exact debit amount will under normal circumstances reflect your regular premium however debits may vary if payment amounts are not received within stated guidelines. I/we authorise the
following: 1. The direct debit user to verify the details of the above mentioned account with my/our financial institution. 2. The financial institution to release information allowing the debit user to verify the
above mentioned account details.
Please ensure you have attached relevant documented proof of your Active ADF Reservist status.
DECLARATION
I certify and acknowledge that I am an active ADF Reservist and qualify for the Navy Health Reservist premium discount, as I satisfy the terms and conditions of the offer. I undertake
to inform Navy Health of any change in circumstances that will affect my eligibility. If I fail to do so, I accept that Navy Health may have the right to reclaim any unpaid premiums in
retrospect or refuse any claims made under the membership.
Sign Here Date
NH_RESERVE_0612
