ESI Inpatriate Health Plan
Underwritten by Grand United Corporate Health Ltd
Application Form
Please send your completed form to Elizabeth Egginton at ESI, GPO Box 3162, Sydney NSW 2001
I WISH TO:
 Join as a new member
 Add a dependent
 Change my details
COMPANY NAME ........................................................................................................................................................
MY DETAILS: (Please print in block letters)
Title (Mr/Mrs/Ms etc)
....................................................................
Surname
Given Names
..........................................................................................................................................................................
Date of Birth
....................................................................
Home Address
..........................................................................................................................................................................
Sex:
.........................................................................
Male 
Female

....................................................................
Postcode
…….......................................
Telephone Home
( ) .............................................................
Work:
( ) .................................................................
Email Address
.........................................................................................................................................................................
Country of Citizenship
.........................................................................................................................................................................
 Single
I require the following cover:
 Family
COVER TO COMMENCE
……../……../…….
DEPENDANTS TO BE COVERED
Surname F
Surname
First Name & initial
Relationship to Member
Partner
Child*
Child*
Child*
Date of Birth
Sex M/F
Please use a separate sheet for additional dependants. *Full time students over 21 and under 25 years of age must be registered annually by special
application.
Is any dependant a full time unmarried student over the age of 21 and under the age of 25 and not liable for
personal income tax? If YES, please provide person’s name, name of educational institution and course being
undertaken.
.....................................................................................................................................................................................
Do any of the people enrolling above suffer from any ailment or condition for which they are receiving treatment or
will require treatment? If YES, please provide person’s name and details of condition (Please provide separate
sheet if insufficient space).
.....................................................................................................................................................................................
...............................................................................................................................................…………………………..
 Yes  No
 Yes  No
LIFETIME HEALTH COVER
Please include evidence if you previously had hospital cover with an Australian Health Fund. This will enable us to determine your
Certified Age at Entry (CAE). If Lifetime Health Cover applies to you and you did not have hospital cover with an Australian Health
Fund, your premium will be calculated according to your birth date(s) at the time of joining.
TRANSFER FROM ANOTHER INSURER / HEALTH FUND
If you’ve had health cover with another insurer or health fund within the last two months you may apply for continuity of cover. Please
include your policy document and membership dates statement from your previous insurer for this to be assessed.
Insurer
..................................................................
Membership No
....................................................
Level of Cover ..................................................................
Date Joined: ........./............/...........Date Paid To: ........./............/...........
AUTHORITY FOR FASTBACK CLAIMS (Direct Credit of Claims)
Account Name
.............................................................
Branch (BSB) Number
..................................................
Account Number
.............................................................
Bank/Financial Institution Name ..................................................
Bank/Financial Institution Address
...................................................................................................................................................
DECLARATION
I request Grand United, until further notice, to credit my/our nominated account with any amount which may be payable by Grand
United Corporate Health in respect of a claim on my membership.
Signature
………………...........................................................
Date
........./............/...........
FEDERAL GOVERNMENT 30% REBATE
Please complete and sign this section if you wish to receive the Federal Government 30% Rebate on private health insurance as a
reduced premium.
■ All people on your membership must be listed on a Medicare card or be entitled to a Medicare card for you to receive the Rebate.
■ You must have a current Medicare card. If your Medicare card is out of date, you cannot qualify for the Rebate until you have
obtained a new Medicare card.
■
ility to claim the Rebate, call the Department of Health and Aged Care on 1800 676 296.
Medicare Card No:
  
Your name exactly as it appears on your Medicare card
Valid to:
 /  / 
..............................................................................................................
Are all the persons listed on your application listed on a Medicare card or entitled to a Medicare card?
 Yes  No
PRIVACY DECLARATION
Grand United and ESI is committed to meeting the requirements of the Privacy (Private Sector) Amendment Act 2000. Grand United
and ESI will assist all health fund members’ access, update and/or correct personal information. Personal information will be
protected by security measures, and will be used by Grand United and ESI for regulatory reporting and for the provision of eligibility
information for service providers/agents/brokers and hospitals as well as to provide, and assist in the development of, member
services which may include use by it's related agencies, but will not be used for any other purpose, such as the sale disclosure to a
third party, without the members approval. Your partner/spouse, if listed on your membership, will have access to membership
information with the exception of cancelling the policy.

If you do not wish to receive information on other Grand United and ESI products and services please tick this box.
If more than one family member over the age of 16 is on the membership, each one signs below.
Signature
Signature
Signature
Signature
………………...........................................................
………………...........................................................
………………...........................................................
………………...........................................................
Date
Date
Date
Date
.........../.........../.............
.........../.........../.............
.........../.........../.............
.........../.........../.............
DECLARATION/AUTHORITY
I declare that the information stated on this form is true and correct in every detail and I agree to be bound by the Fund Rules of
Grand United Corporate Health Limited. I acknowledge that the organisation shall have the right to cancel my membership if the
information provided by me is inaccurate or misleading. I have read the Important Information section in the Corporate Health Plan
booklet and understand all conditions including those regarding waiting periods and pre-existing conditions. If transferring from
another fund, I authorise Grand United Corporate Health Limited to obtain any information necessary from my previous fund.
Signature
………………………..........................................................
Date
.........../.........../.............
WHAT HAPPENS NOW?
Please send your completed form to Elizabeth Egginton at ESI, GPO Box 3162, Sydney NSW 2001
Within a few weeks of your application being processed, you will receive a membership pack from Grand United Corporate Health
Fund. This pack will include:



Your Membership Card
Your Member Booklet
Claim Forms and details on claiming
Once you have received this information, you can contact Grand United Corporate Health on Freecall 1800 249 966 with any queries.
If you need further assistance, please contact Elizabeth Egginton at ESI on 1300 365 385.