Ngāti Whātua Ōrākei

Health Insurance Enrolment

Complete all sections of this form to enrol into the Ngāti Whātua Ōrākei Health Insurance. To be eligible, you must be a registered Ngāti Whātua Ōrākei hapū member. Anyone 18 and over must complete a separate form.

Registered and eligible Ngāti Whātua Ōrākei hapū members will be covered under the Ngāti Whātua Ōrākei Health Insurance. Any additional cover for yourself or any cover for non-member whānau will be at your own cost. For any assistance, free phone the friendly nib team on 0800 nib nwo (0800 642 696).

Personal details

Title

First name

Middle name

Surname

Date of Birth

Biological gender

Male

Female

Preferred gender (if different to biological gender)

Contact details

Home phone

Mobile phone

Work phone

Address

Or enter my address manually

Children details

Your insurance policy benefits will apply to all of your tamariki who are under 18 and are registered members of Ngāti Whātua Ōrākei.

Full name

Date of Birth

Gender

Male

Female

Yes, my child is under 18 and a registered Ngāti Whātua Ōrākei member

Non-member details

If you want to add whānau who are not registered Ngāti Whātua Ōrākei hapū members please fill out their details and someone from nib will contact you:

Full name

Date of Birth

Gender

Male

Female

Person who referred me

Full name of member

Yes I've read and agree to the privacy policy for myself and everyone on this enrolment form and I have authority to provide personal information about everyone on this form