1. I understand that:
   1. the information Southern Cross collects in this application form and in the wider application process will be used to consider and process the application for health insurance (and Cancer Assist or Critical Illness where relevant) and, if approved, consider the specific terms that apply to the applicable policy, to administer the applicable policy and for marketing purposes.
   2. if any of the information requested as part of this application is not provided, it may delay the application being processed, or result in Southern Cross not providing the people named in this application with cover or associated benefits.
   3. the people named in this application are entitled to have access to, and request correction of, any of their personal or health information held by Southern Cross.
2. I authorise Southern Cross to collect from, and to disclose to:
   • my husband/wife/partner (if named in this application);
   • any person(s) nominated in writing by me;
   • third parties such as health services providers and medical authorities (including ACC and Ministry of Health), agents, contractors, suppliers and other business partners;
     
     information relating to people named in this application form and I authorise these parties to disclose to Southern Cross and receive from Southern Cross this information.
     
     I authorise Southern Cross to collect information from a previous Southern Cross health insurance and/or Cancer Assist policy and/or Critical Illness policy (including previous application(s), membership certificate(s) and/or claims)
3. In relation to any other people named in this application, I confirm that:
   • I am authorised to complete this application form on their behalf;
   • I am authorised to disclose to Southern Cross and to receive from Southern Cross their personal and health information;
   • I have made each of them aware of the contents of this application; and
   • each of the people named have authorised me to give the acknowledgements, undertakings and authorities set out above on their behalf.

Once your application has been accepted, management of this and other personal and health information provided to Southern Cross is subject to the terms of the Southern Cross Privacy Statement. For an up to date copy of the full Southern Cross Privacy Statement, please refer to your policy document, visit our website at www.southerncross.co.nz/privacy or contact us on 0800 800 181.