Experience New Zealand Insurance

If you require any assistance in completing this application form, please call Simurgh Risk Management Ltd on +64 7 839 4023 or email info@simurgh.co.nz.

Application Form

SECTION 1 - APPLICANTS DETAILS

Include country code
Male Female

dd/mm/yyyy
Other Applicants Details
Spouse

dd/mm/yyyy
Male Female
Dependants:

dd/mm/yyyy
Male Female
SECTION 2 - EMERGENCY CONTACT (person you would like us to contact in case of a major emergency)

Include country code
SECTION 3 - COVER OPTIONS (please tick one of the following boxes)
Experience NZ Prime
Experience NZ Lite
Experience NZ Lite with specified items
SECTION 4 - PERIOD OF INSURANCE

dd/mm/yyyy

dd/mm/yyyy
SECTION 5 - MEDICAL INFORMATION (Complete this section if you require cover for pre-existing medical conditions)
1. Are you currently suffering from a medical condition, illness or injury?
No Yes
2. Have you been admitted to hospital in the past 12 months?
No Yes
3. Are you currently taking any medication?
No Yes
4. Have you ever received treatment for any type of:
  • Heart ailment No Yes
  • Circulatory conditions No Yes
  • Cancer No Yes
  • Back or spinal problems No Yes
If you have answered yes to any of the questions above, please answer the following questions:
1. Please describe your medical condition
2. What medication or treatment has been prescribed to treat your medical condition?
3. What date did you last visit your doctor?

dd/mm/yyyy
4. What is your doctor’s name and address?
SECTION 6 - SPECIFIED ITEMS
  • Prime - Please specify items (or pairs of items) valued over NZ$2,500. Property valued at under NZ$2,500 is automatically included in the standard cover for this insurance plan.
  • Lite - property is not automatically covered under this plan. Please specify items you wish to insure under this plan.
  • For both plans the maximum value per tem you can specify is NZ$10,000 and up to a total limit of NZ$30,000.
ITEMS:
(please provide brand and model details and note the replacement value)

Declaration

I/we declare that:
  • I/we confirm that the information and answers written on this application are a complete and truthful record.
  • I/we understand that OrbitProtect Medical / Travel Insurance is underwritten by Lumley General Insurance (N.Z.) Ltd.
  • I/we authorise Simurgh Risk Management Ltd, OrbitProtect Ltd and Lumley General Insurance (N.Z.) Ltd (which includes both representatives, consultants and their international assistance agent, any re-insurer and education provider) to collect, hold and user information about the Applicant for the purpose of deciding to issue a policy, specific terms applying and otherwise relating to matters covered but the policy terms.
  • I/we authorise any doctor, hospital, clinic or other person to give Simurgh Risk Management Ltd, OrbitProtect Ltd and Lumley General Insurance (N.Z.) Ltd any and all information concerning my current and past medical history. A photocopy of this authorisation shall be valid as the original. The insured person has the right to access and correct health and personal information held about them.
  • I/we understand that this insurance contract is made up of this application, the policy wording and the Certificate of Insurance. It is my/our responsibility to read and be familiar with the policy wording. I acknowledge that the policy contains conditions and exclusions.