EBS Standard Plan Application
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MOE Employee Number
Union
None
NZEI
PPTA
TEU
TIASA
PSA
*
I am a new EBS Health Care Applicant
*
I am a
current
EBS Health Care Subscriber
*
I am interested in receiving information about the EBS Hospital Cover (Highly Recommended)
Contributor & Family Member Details :
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Title
Family Name
*
Given Name
*
Sex
*
DOB
*
(DD/MM/YYYY)
Contributor
Male
Female
Residential Address :
Street:
*
City:
*
Suburb:
*
Postcode:
Contact Details :
Worksite Name:
*
Telephone Private:
Telephone Work:
*
Mobile:
Email:
*
Payment Details :
*
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Payment Frequency :
Fortnightly Payments
Monthly Payments
Annual Payments
Payment Method :
I wish to pay by Direct Debit.
(Click here to download direct debit form)
I wish to pay by Salary Deduction. I authorise EBS Health Care to make deductions from my salary and acknowledge that deductions may change from time to time as determined by EBS Health Care.
New Deduction Authority.
Replaces Existing Deduction Authority.