If you would like HICA to review your healthcover needs, please complete our online assessment form. The form below should be used for general enquiries only. In order that we can appropriately address your enquiry, we may need specific information about your current situation including your current health cover status. In many cases, we will forward our response by post, and therefore require your postal address. Please complete the fields below and submit your enquiry. * Denotes mandatory fields

Your Details Title: MrMrs Miss Ms Sir Lord Dr Str Fthr Rev Bro Prof Capt Maj * First Given Name: Second Given Name: * Surname: * Birth Date: (dd | mm | yyyy)   ie 09 | 07 | 2001  (What's this for?) Employer: Occupation: Your Spouse Details Birth Date: (dd | mm | yyyy)   ie 09 | 07 | 2001 Occupation: Your Contact Information * Postal Address:     * Suburb: * State: VicNSW QLD SA Tas NT ACT WA All * Postcode: Contact Phone: HomeWork Mobile   Area Code: Number: * E-mail address:   IMPORTANT: For your own security HICA requests that you provide a trusted email address.   A trusted email address is any address provided by a company, an internet service provider, an educational institution or an organisation. Generally, an email address that is supplied for free or is internet-based is not considered a trusted email address by HICA (eg Hotmail, Yahoo and Gmail addresses). Your Present Health Insurance Cover Current Insurer Currently UninsuredACAAMA CBHS CDH Credicare Defence Health Federation HCI HIF Healthguard Health-Partners Lysaght Navy Health NRMA Health Phoenix QCH Qld Teachers R&T Health Reserve Bank Police Health St Lukes Teachers Fed Transition Druids Vic Druids NSW FAI Betterhealth Illawarra Health Mutual Health Aust. Country Health HBF GMF Health IOOF IOR Latrobe MBF AXA HBA Mutual Community NIB Worldcare Assist Seniors Advantage Transport Westfund Mildura Dist Hosp Fund Australian Unity GEHF HCF Manchester Unity SGIO Health SGIC GMHBA Limited IMAN Medibank Private AHM Grand United Hospital Policy Level of cover: Ancillary Policy Level of cover: Current premium (after deducting the Federal Government Rebate) $ Per UnknownWeekly Fortnight Month Quarter Half Year Year Comments and Queries Extra Comments or Queries