30pm Sat 8am 1pm AEST Visit an nib Retail Centre nib health funds limited abn 83 000 124 381 Head Office 22 Honeysuckle Drive Newcastle NSW 2300 nib2513010713 brPage 2br This Direct Debit Request DDR Service Agreement is issued by nib health funds l ID: 73935
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Your personal detailsResidential address in Australia (include suburb, state and postcode) Suburb State Title Surname Date of Birth To review nib’s direct debit request service agreement, refer to the Policy Booklet at Signature/s / / Account Holders signature/s Direct Debit Request & Claims Bene t FormI/We authorise nib health funds limited A.B.N. 83 000 124 381, User ID number 000488 to arrange for funds to be debited from my/our nominated account via the Bulk Electronic Clearing System at the nancial institution shown below according to the schedule speci ed below. Claims deposited directly into your bank account Use the above bank account Select a different bank account Please provide details below. Pay your premium automatically Automatic payments from your nominated bank accountName of Bank, Building Society or Credit Union Account number BSB number First Debit Date / / Payment frequency (please tick) Fortnightly Monthly Quarterly Half Yearly Yearly Fortnightly premiums are only available Monday to Friday. All other options are only available from 1st to 27th of the month. if you choose direct debit you will receive up to 4% Automatic payments from your nominated credit cardCard Number / / Credit Card Type (please tick) Visa Mastercard American Express / / Payment frequency Fortnightly Monthly Quarterly Half Yearly Yearly Fortnightly premiums are only available Monday to Friday. All other options are only available from 1st to 27th of the month. 4% discount does not apply to credit card payments. nib345101_Premium Payment & Claims Bene t Form_1015