Refund form - Allianz Global Assistance OSHC

Overseas Student
Health Cover
Refund form
Please complete form in CAPITAL letters and attach evidence required. Do not forget to complete all fields (including passport number
and nationality) and sign and date on the reverse of this form. Refunds are paid on a monthly pro-rata basis.
Personal and policy details
Policy number (In most cases
this will be your student number):
Policy expiry date: _ _ /_ _ /_ _ _ _
Passport number:
Nationality:
Given name:
Family name (surname):
Date of birth: _ _ /_ _ /_ _ _ _
Mobile:
Email address:
Are you a sponsored student and your sponsor has paid for your OSHC?
Yes
No
If yes, you may not be entitled to receive a refund from Allianz Global Assistance. Please refer to your institution for approval to attach to
this application.
Please select the reason for this refund
1.You purchased an OSHC policy but are not coming to Australia. Refer to section A for Evidence Required.
2
.You are leaving Australia earlier than expected. E.g. you completed your course early, your visa extension was not granted or family illness
requires you to return to your home country. Refer to section B for Evidence Required.
3. You no longer hold a student visa. R efer to section C for Evidence Required.
4
.You have a simultaneous OSHC policy with another provider. Refer to section D for Evidence Required.
5.You have simultaneous OSHC policies with Allianz Global Assistance. Refer to section E for Evidence Required.
6.Your OSHC policy is longer than your student visa. Refer to section F for Evidence Required.
7. You need to downgrade your policy. Please provide passport ID page for all family members. Refer to section G for Evidence Required.
Evidence required
A • Notification of refusal of application for a Student visa; or
•
If you did not apply for a student visa or are not coming to
Australia for other reasons, please confirm by ticking here
(Your visa status will be checked with the Department of
Immigration)
B •
Confirmation of completion; or Cancelled Confirmation of
Enrollment; and
•Flight itinerary (If your flight itinerary changes, you will need to
ensure that you are covered until your new departure date)
C •
Evidence provided by Department of Immigration confirming
your previous student visa
D •
Certificate of Insurance from another OSHC provider (showing
commencement and expiry dates, listed beneficiaries and type
of policy); and
•
If you have not arrived in Australia yet, please confirm by ticking
here
; or
•Provide entry to Australia details (flight itinerary or eTicket)
E • Provide all of your current policy numbers ______________________________________________; and
•
If you have not arrived in Australia yet, please confirm by ticking
here
; or
•Provide entry to Australia details (flight itinerary or eTicket)
F •
If you have not arrived in Australia yet, please confirm by ticking
here
; or
•Provide entry to Australia details (flight itinerary or eTicket)
G
Family not arriving to Australia
•
Notification of refusal of application for a Student dependant
visa; or
•
If your family members never applied for a student dependant
visa or are not coming to Australia for other reasons, please
confirm by ticking here
; or
•
If family members hold a current student dependant visa, but
are no longer coming to Australia, please confirm by ticking
here
(Your visa status will be checked with the Department of
Immigration)
Family departing Australia
•Flight itinerary for all family members
(If your flight itinerary changes, you will need to ensure that you and
your family members are covered until your new departure date)
Family arriving later than expected
•Expected arrival date _ _ /_ _ /_ _ _ _
(If this date changes, you will need to ensure you and your family
members are covered from the new arrival date)
Other
•Please explain your circumstances
_________________________________________________
_________________________________________________
_________________________________________________
*Please note: If you were outside of Australia and held a student visa for a continuous period of 3 months or greater, contact us to discuss your options. Allianz Global Assistance
may be required to notify the Department of Immigration of policies which are cancelled and refunded.
Refund Form
Payment Options
By Credit Card
Only available where your policy was purchased by credit card directly from Allianz Global Assistance in the last 12 months.
Your refund will be returned to the credit card used to purchase the policy. Please note if the credit card isn’t in your name, then you will need to
contact the owner to arrange reimbursement.
Please select an option below if:
• Your policy was not paid by credit card; or
• Your policy was paid more than 12 months ago; or
• Original credit card used to purchase policy has expired or been cancelled
Deposit into your local bank account
Deposit into someone else’s account
Account holder name:
Account holder signature:
BSB (6 digits):
Account number :
Name of financial institution:
Telegraphic transfer to your overseas account
Telegraphic transfer to someone else’s account
Please note: In the case of incorrect/incomplete information being provided, bank charges will be deducted from your refund amount.
Account holder name:
Account holders address (Include City/State/Prov/Zip Code):
Account holders phone number (overseas):
Bank /fund name:
BSB/Swift/BIC code:
Account number:
IBAN or IFSC (where applicable):
Routing number (where applicable):
Bank address (full street address including building and street number):
Currency which your account is held in:
Declaration
By signing this refund form, I declare that all statements and particulars contained on this from are true and correct.
Please sign
Signature (Policy holder only):
Date: _ _ /_ _ /_ _ _ _
General Processing of Refunds
•
•
•
•
•
ENSURE ALL DETAILS PROVIDED ARE CORRECT
We will endeavour to process all refunds within 10 working days of receiving a completed refund form (including all necessary supporting evidence).
We may contact you to clarify any details or request further information in order to process your refund.
A minimum cover period of 3 months is payable if cover is cancelled after arriving into Australia.
There is no minimum cover period payable if cover is cancelled prior to arrival in Australia.
Please return completed form to:
Allianz Global Assistance OSHC
Locked Bag 3001
Toowong QLD 4066
Phone: 13 OSHC (13 6742)
Fax: +61 7 3305 7009
Email: [email protected]
Allianz Global Assistance Overseas Student Health Cover policies are authorised under a Deed entered into between Lysaght Peoplecare Limited and the Australian Government
through the Department of Health and Ageing. Allianz Global Assistance OSHC is managed by AGA Assistance Australia Pty Ltd ABN 52 097 227 177. Lysaght Peoplecare Limited
ABN 95 087 648 753, a private health insurer under the Private Health Insurance Act 2007 (Cth) is the underwriter of Allianz Global Assistance OSHC policies.
OSHC002 10/15
The information that you provide is collected, used, and disclosed in accordance with our Privacy Policy available on request or view it at www.allianz-assistance.com.au under the Privacy
and Security link. By submitting your personal information, you agree and consent to our Privacy Policy. For example, we use and disclose it to administer your Allianz Global Assitance
OSHC policy and otherwise manage the policy (including complying with regulatory requirements in relation to OSHC). The information may be disclosed to educational providers,
the underwriter, government departments responsible for OSHC, medical practitioners, hospitals and other medical and assistance providers as required to including to notify the
Department of Immigration and Border Protection of the granting of the credit. If you would like to gain access to your personal information, please contact Allianz Global Assistance.