Student Insurance Registration

Step 1 of 3

First Name

Surname

Gender

Date of Birth

Commencement Date of Cover

Name of Institution

Physical Address

Email Address

Phone Number

Basic coverage for essential needs.

Select Copper

Enhanced coverage with additional benefits.

Select Silver

Comprehensive coverage for peace of mind.

Select Gold

Upload Passport Size Photo

First Name

Surname

Relationship

Phone

First Name

Surname

Relationship

Phone

Please indicate if you or any dependants have any of the following medical conditions:

Seen a doctor or other healthcare professional in the last three years?

Admitted to hospital, had an operation/procedure, or had an investigation in the last seven years?

Please indicate if you have any of the following medical conditions:

Condition/Category	Principal Member
1. Heart & Circulation Read More
2. Breathing & Respiratory Read More
3. Bladder & Kidneys Read More
4. Reproductive Organ Read More
5. Digestive System Read More
6. Ear, Nose & Throat Read More
7. Eyes Read More
8. Endocrine Read More
9. Back & Muscles Read More
10. Neurological Read More
11. Psychological Read More
12. Tumours & Growths Read More
13. Blood Read More
14. Skin Read More
15. Sexually Transmitted Infections (STI's) Read More
16. Pregnanacy Read More
17. Pregnanacy Read More

Question Number	Condition/Diagnosis	Medication	Currently Receiving Treatment	Date of Last Treatment	Healthcare Provider