Payment authority form

Payment Authority
Complete the HCF Group Payroll Deduction Authority if paying through your employer.
Complete and send to:
HCF
GPO Box 4242,
Sydney, NSW 2001
Fax 02 9290 0128
Visit any one of our
branches
Complete Credit Card Authority if paying by Credit Card.
Complete the Ezipay Direct Debit Request if paying through bank, building society or credit
union debit.
HCF Membership No.
1 Member’s personal details (PLEASE USE CAPITAL LETTERS AND A BLACK PEN)
Title
First name
Middle initial
Surname
Home address:
Unit No.
Street No. Suburb Phone - home Postal address (if different from your home address)
Suburb Sex (Please mark ‘X’)
M
F
Street name
State
Phone - work
Postcode
Mobile
State
Postcode
Email
@
.
Date of birth (DD MM YYYY) Date you wish your membership to commence (DD MM YYYY)
.
2 Payment method (Please mark ‘X’)
HCF offers you a number of easy ways to pay your premiums. Please fill out one of the options below to pay your premiums automatically.
Ezipay Direct Debit (please complete Section 2a)
Credit Card Authority (please complete Section 2b)
Payroll Deduction (please complete Section 2c)
a) Ezipay Direct Debit Request
I/We authorise The Hospitals Contribution Fund of Australia Limited User ID Number 245164 to arrange for funds to be debited
from my/our account and as prescribed below through the Bulk Electronic Clearing System (BECS).
(Please mark ‘X’)
Weekly
Fortnightly
Monthly*
Quarterly*
Half yearly*
Yearly*
(DD MM YYYY)
Please debit on the
day* of the month. First debit to occur on
(*Please nominate day: Debit dates of 28, 29, 30, 31 are only available for weekly and fortnightly debits)
Details of account to be debited (all details must be supplied)
Name of financial institution
BSB No. Branch
Account holder name (first initial and surname)
Account No.
This authorisation is to remain in force in accordance with the terms described in the HCF Direct Debit Customer Service Agreement.
b) Credit Card Authority
Cardholder name (exactly as it appears on your card)
Type of card (Please mark ‘X’)
Debit frequency (Please mark ‘X’)
Visa
Monthly*
Mastercard
American Express
Credit card No. Quarterly*
Half yearly*
Yearly*
Expiry date (MM YY)
Please debit my account on the
day* of the month
(*Please nominate day: Debit dates of 28, 29, 30 and 31 are not available)
This authorisation is to remain in force in accordance with the terms described in the HCF Direct Debit Customer Service Agreement.
c) Group Payroll Deduction Authority
Payroll deductions are available only when your employer has an arrangement with HCF.
Employer’s name
Payroll or employee ID
I hereby authorise my employer to deduct from my wages or salary. (Please mark ‘X’)
Weekly
Fortnightly
Monthly
Quarterly
Half yearly
Yearly
Employee’s detailsMiddle
Title
First name initial
Surname
Total contribution
deductions (if known)
Date marking the end of the first
deduction pay period (DD MM YYYY)
Health $
Other contribution details
If you wish to pay for other HCF memberships please give their details below:
Membership No. Full name
Cash Assist $
Total $
Membership No. Full name
3 Declaration (Please read and sign)
I acknowledge and agree that:
• Where payment method is Group Payroll Deduction, I authorise my employer to deduct from my wages or salary.
• Where payment method is Credit Card Deductions, I authorise HCF to debit the account nominated.
• Where payment method is Ezipay Direct Debit Deduction, I authorise HCF to debit the account nominated.
I declare all information provided on this form to be true and complete.
How HCF collects, uses, discloses (which may include obligations to overseas recipients in compliance with its privacy obligations) and keeps and
secures personal information including how to opt out from direct marketing, how to request access to and correction of your personal information
or how to complain about a privacy breach and how this is handled by HCF is explained in the HCF privacy policy. For a copy of this policy, call our
member services team on 13 13 34 or go to hcf.com.au.
Member’s Signature
x
Date (DD MM YYYY)
Account holder’s signature
or Cardholder’s signature
(if different from member)
x
Date (DD MM YYYY)
The Hospitals Contribution Fund of Australia Limited. ABN 68 000 026 746
AFSL 241 414. HCF Life Insurance Company Pty Limited. ABN 37 001 831 250
AFSL 236 806
Head Office: 403 George Street, Sydney, NSW 2000
Telephone: 13 13 34. Postal Address: GPO Box 4242, Sydney NSW 2001
Email: [email protected] Internet: hcf.com.au
HCF Payment authority 0315