Direct Debit Request Form

  • Request and authorise Union Health Fund (Queensland Teachers’ Union Health Fund Limited), User ID 80261 to arrange, through its own financial institution, a debit to your nominated account any amount Union Health has deemed payable by you.

  • This debit or charge will be made through the Bulk Electronic Clearing System (BECS) from your account held at the financial institution you have nominated below and will be subject to the terms and conditions of the Direct Debit Request Service Agreement.

By completing this form, you agree to the Union Health Terms and Conditions and declaration listed on the form.

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Request and authority to debit

Payment frequency

Declaration

By providing Union Health with a valid instruction in respect to my Direct Debit Request, I understand and agree to the terms and conditions governing the debit arrangements between myself and Union Health set out in this request and in my Direct Debit Request Service Agreement.
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