Refund work scheme | Southern Cross Health Insurance

If we've contacted you to request your bank account details, so we can refund premium, please complete the form below.

Please name your organisation and confirm you have authority to complete this form on its behalf.

Name of the organisation *

Are you authorised to complete this form on behalf of the organisation?

Yes

No

You must have authority to complete this form. If you are not authorised please ask the person with authority to complete the form.

Please advise the organisation’s bank account details for this refund.

Account name *

Account number *

Master Group ID number *

Please attach a document displaying the company name and bank account, such as a bank deposit form.

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

Add another attachment

Please confirm the organisation address.

Street number and name *

Suburb

Town / City *

Postcode

Country *

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 None

First name *

Last name *

Date of birth *

Email *

Contact number *

Street name and number *

Suburb

Town / City *

Postcode

Country *

I confirm that all information supplied in this form is true and correct. *