Student Dependent Declaration Form

Student First Name

Membership #

I declare that:

The dependent will not be registered as a full-time student by 1 March 2025, does not meet the conditions of the options above and would therefore be required to commence their own policy

Our Member Services Team will provide written confirmation of any changes or updates.

If the dependent would like to discuss taking out their own policy, please provide the best contact details for them and any other information that may assist.

The statements made and information provided are true, correct and complete; and

I undertake to inform Emergency Services Health immediately of any change in the circumstances of the above-named dependent; and

I confirm that the above-mentioned dependent has given permission for their contact details to be provided for the purpose of discussing their private health cover options directly with Emergency Services Health; and

I have read and understand Emergency Services Health privacy notice.

Full Name of Person Completing Form

Date

Option 4 - Remove Dependent from Policy