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OSHC Refund Form

Uploaded by

Husnain Arif
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101 views

OSHC Refund Form

Uploaded by

Husnain Arif
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

OSHC Refund Form

To request a refund please complete and sign this form, attaching any required evidence and email to
[email protected]

Section 1: Policyholder details


nib OSHC Policy Number Passport Number Passport Country of Issue

Title Given name/s Surname

Date of birth (DD/MM/YYYY) Email

Section 2: Reason for refund


Please select a reason for refund and supply all supporting documentation.

Upon assessing your refund request, nib may request further information pertaining to your situation in order for the
refund to be processed.

Section 3: Refund Details


To request a refund please select one of the available options. Refund to Credit Card is not a valid refund option.

Payment originally made through Flywire and Refund to be processed via Flywire

Refund will be processed to original credit card or bank account.

Deposit into Australian bank account

Bank/Financial institution name BSB number

Account name Account number

Deposit into an International bank account

Swift/BIC code (8 or 11 characters) Account number or IBAN

Account holder’s name

Account holder’s address including house no./street name/city/state/prov/zip code (no PO Boxes)

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OSHC Refund Form
Please select currency: You must select a currency and confirm it is accepted by your Bank/Financial Institution before
applying for your refund.

Bank/Financial institution name Bank/Financial institution country

Bank/Financial institution street address including City/State/Prov/Zip Code (no PO Boxes)

Passport number PAN number (India only)

Section 4: Declaration (If you do not provide the Declaration in full, we may be
unable to process your refund)
 

 

 

By signing this form, you declare that:


„ The information provided herein is accurate and complete;
„ You acknowledge that nib may, at its discretion, contact you for further information
„ You acknowledge that once the refund is processed that the insurance provided through nib will be terminated and will
no longer provide coverage.
Customer’s signature Date

Privacy
The information that you provide is collected for the purpose of arranging a refund of your nib OSHC premium. This information
will be managed in accordance with nib’s Privacy Policy, accessible at https://www.nib.com.au/legal/privacy-policy. If you
would like to gain access to your personal information, please contact nib as outlined in the Privacy Policy.

nib health funds limited ABN 83 000 124 381


nib254615 0522

OSHC Refund Form 2/2

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