info@ahca.com.au
Please take the time to complete the below form to receive your Free Evaluation and obligation free 14 day cover note. The more details you complete the more accurately our evaluation can be tailored to your needs.
Free Health Insurance Evaluation
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Title:
Mr
Mrs
Ms
Miss
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First Name:
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Surname:
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Postal Address:
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Suburb:
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State:
VIC
NSW
QLD
TAS
SA
NT
WA
ACT
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Post Code:
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Date of Birth:
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Sex:
Male
Female
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Daytime Phone Number:
Email:
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Do you currently have Health Insurance:
Please Select
Yes
No
If "Yes" which Fund:
Table Name:
Which Type of Cover:
Please Select
Hospital Only
Extras Only
Hospital & Extras
Current Premium:
Premium Paid:
Please Select
Weekly
Fortnightly
Monthly
Quarterly
Half Yearly
Yearly
Coverage Required:
Please Select
Single
Couple
Family
Single Parent
Partners Date of Birth:
Childrens Ages and are they Students:
Do you earn $50000 as a Single/$100000 as a Family:
Please Select
Yes
No
What Cover do you Require:
Please Select
Hosptial Only
Hospital & Extras
Extras Only
To Reduce Premium which Excess would you consider:
Please Select
Up to $1000
Up to $500
Up to $250
Nil
Level of Extras Required:
Please Select
None
Basic
Standard
High
What Extras you would like Covered:
Have you held Hospital Cover since 01/07/2000:
Please Select
Yes
No
Partner held Hospital Cover since 01/07/2000:
Please Select
Yes
No
Do you hold a current Medicare card:
Please Select
Yes
No
Do you require Ambulance Cover:
Please Select
Yes
No
Comments / Concerns:
