I declare that:

• The information I’ve provided in this request is correct and complete;
• I agree to be bound by the Fund Rules and Constitution of TUH as amended from time to time;
• I understand that any changes to my cover may change my premiums;
• I am aware of that details of TUH's privacy policy and I consent to TUH collecting, using and/or disclosing my personal information for the purposes stated in the policy;
• I am authorised to act on behalf of all other people that I have named in this request; and
• I am aware that I have a 30 day cooling-off period that commences from the change of cover date.