Payment details | Southern Cross Health Insurance

If we’ve contacted you to request your bank account details so we can make a payment to you as part of remediation action, please complete the form below.

The bank account information you enter here will only be used for the purposes of this payment. We will not use it to change the account your claims are paid into or the account your premiums are paid from.

Please provide your bank account details for this payment

Note: The bank account details provided here will only be used for remediation payment.

Bank account name *

Bank account number *

Reference code *

Please select Please select CLR PRM

Please submit proof of your bank account if you have been asked to

You can use a screenshot of internet banking, a deposit slip, or a copy of a statement. All transaction details can be blanked out, but please ensure the proof includes the full account number and the name that's listed on the bank account.

Accepted file types: DOC, DOCX, PDF, JPEG, JPG or PNG (Max file size 2MB).

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Enter your personal details

These details help us verify who you are so we can deal with your enquiry as quickly as possible.

Title

Optional Optional Mr Mrs Miss Ms Mx

First name *

Last name *

Date of birth *

Email *

Contact number *

Street name and number *

Suburb

Town / City *

Postcode

Country *

Policy number *

By submitting this form, you acknowledge and agree that personal and health information provided to us (including any supporting documents) will be collected, stored, used and disclosed in accordance with the terms of our Member Privacy Statement.

Please provide your payment details

Please provide your bank account details for this payment

Please submit proof of your bank account if you have been asked to

Enter your personal details

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