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Application form
International Student travel insurance
This application form is to be completed in English, for policies with a start date of insurance on or after 10 May 2023.
If you need assistance in completing this application form, please call your designated agent or email info@[Link]
Eligibility
You can only get cover under this policy if you meet all the criteria below.
• You hold or intend to hold throughout your journey a current visa permitting you to study in New Zealand, or as a parent or legal guardian
you hold a ‘Guardian of a Student’ visa
• You’re enrolled at a New Zealand education provider and you regularly attend classes for which you enrolled up until the time you
submitted a claim
• You’re aged 55 years or under at the date your insurance starts
• You haven’t been refused cover, had an insurance claim declined, or had an insurance policy cancelled or voided, because of fraud
by ticking this you confirm that you and anyone else listed on this policy meet this criteria
Policyholder details
Mr. Mrs. Miss. Ms.
Dr. Mx. Master.
Family name (As shown in passport) First/ given names (As shown in passport) Date of birth (Day/Month/Year)
*To be eligible for this policy, all insureds must be aged 55 or under at the
Home country date the insurance starts.
Other family to be insured (if any)
Family name (As shown in passport) First/ given names (As shown in passport) Date of birth (Day/Month/Year)
*To be eligible for this policy, all insureds must be aged 55 or under at the
date the insurance starts.
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Contact details in New Zealand
Address
Unit/Street number and name: Suburb: Town or City: Postcode:
Mobile Email
Student ID number (If known) Education provider
Emergency contact/Guardian
Family name (As shown in passport) First/ given names (As shown in passport) Relationship
Mobile Email
Period of insurance
Start date (Day/Month/Year) End date (Day/Month/Year)
*(The date of departure from your home country, or if you are in
New Zealand the date you want cover to begin)
Cover under section C.2.1 of your policy commences on the date we issue your certificate of insurance.
Cover under all other sections of the policy commences on the date your journey starts.
Premium
Premium $
Medical questions
Pre-existing medical conditions are not automatically I have read and understood ‘What is a pre-existing medical condition?’
covered under your International Student policy. If you have any
pre‑existing medical conditions that you would like to seek cover for, I do not have any pre-existing medical conditions
please declare these now. (Select this option if you do not have any pre-existing medical conditions).
Pre-existing condition(s) that you do not want to seek cover for,
or do not tell SCTI about, will remain excluded under your policy. I wish to apply for cover for my pre-existing medical condition(s)
(Select this option if you have any pre-existing medical condition(s) that you would like to apply for cover for).
To seek cover for your pre-existing medical conditions, please
What is a pre-existing condition? call us on 0800 784 691 (within New Zealand) or +64 9 979 6597
(outside New Zealand) within 31 days of purchasing your insurance
For the purposes of the International Student policy, a ‘pre‑existing
to complete a medical assessment, and we will advise whether we
condition’ is: in relation to each person named on your certificate of
can offer cover for your preexisting medical condition(s).
insurance, any illness, injury or health symptom which that person
is aware of, or a reasonable person in that person’s circumstances I have a pre-existing medical condition(s) but do not want to
ought to have been aware of, which in the last 3 years prior to your apply for cover for it
start date of insurance, that person has sought, received, been
(Select this option if you do NOT want to apply for cover for your pre-existing medical condition(s),
recommended or is waiting for: advice from a health professional; and accept that they will not be covered under this policy).
tests, investigations or specialist consultations; care, treatment, or
medical attention including surgery; or medication or a prescription
for medication, whether or not a medical diagnosis has been made.
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Declaration
You (the applicant or parent/guardian of an applicant aged under 18 years) declare and undertake to Southern Cross Benefits Limited
(SCTI) that:
1. You confirm that you meet the eligibility criteria set out in the policy wording and will continue to meet the criteria during the period of
insurance.
2. You are 18 years or older (or as the parent or guardian of the above applicant and you accept the terms of this declaration on behalf of the
applicant) and you are authorised by each person named as an insured person to complete the application process for the policy on their
behalf, make changes or cancel the policy on their behalf, submit any claim under the policy on their behalf, and disclose and receive such
information as may be required by SCTI.
3. You are authorised by the credit card holder to charge the credit card as the method of payment for the policy.
4. Your policy contract is made up of the policy wording (a copy of which you acknowledge has been made available to you at www.
[Link] prior to making this declaration), certificate of insurance and any endorsements to your certificate of insurance
and any special terms and conditions in writing from us confirming any addition or variation of your policy. It is your responsibility to read
and be familiar with the policy wording. You acknowledge that your policy contains conditions, limits and exclusions.
5. If any information given to us is incomplete, false or inaccurate, SCTI may void or cancel your policy and refuse to pay any claim.
6. You and any other persons to be insured under this policy will be travelling together.
7. You authorise SCTI to collect and share personal information about you and the other persons to be covered in accordance with SCTI’s
privacy statement. You can access SCTI’s privacy statement at [Link]/privacy
8. I accept all communications will be by email. If I have not provided my email address to SCTI in this application, then SCTI may send
communications to my designated agent instead of me.
Signature of policyholder
Signed (Applicant or parent/ guardian if aged under 18 years)
Date signed
Financial strength rating
Southern Cross Benefits Limited has an A (Strong) financial strength rating given by Standard & Poor’s (Australia) Pty Ltd.
The Rating Scale is:
AAA (Extremely Strong) AA (Very Strong) A (Strong)
BBB (Good) BB (Marginal) B (Weak)
CCC (Very Weak) CC (Extremely Weak) SD or D (Selective Default or Default)
R (Regulatory Supervision) NR (Not Rated)
Ratings from ‘AA’ to ‘CCC’ may be modified by the addition of a plus (+) or minus (-) sign to show relative standing within the
major rating categories. Full details of the rating scale are available at [Link].
Standard and Poor’s (Australia) Pty Ltd is an approved agency under the Insurance (Prudential Supervision) Act 2010.
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