Insurance membership request form

Please complete all the details below for your insurance membership request and allow up to seven business days for your request to be processed.

Please note, all multi visit swim passes expire 12 months from the date of purchase. Customers purchasing a swimming multi visit pass for the first time will be required to purchase an access card ($3.70).


Please enter your contact information

Please enter the contact's name.
Please enter the organisation's name.
Please enter the contact's phone number.
Please enter the contact's email address.

Member details

Please enter the member's first name.
Please enter the member's last name.
Please enter the member's address.
Please enter the member's suburb.
Please enter the member's postcode.
Please enter the member's phone number.
Please enter the member's email address.
Please select the member's date of birth.

Select your membership option

Please select an option.

Invoicing details

Please enter the organisation's name.
Please enter the invoicing contact's name.
Please enter the invoicing address.
Please enter the invoicing suburb.
Please enter the invoicing postcode.
Please enter the invoicing phone number.
Please enter the invoicing email address.
Please enter your claim number.

Membership start date

Please select the start date

Supporting Documentation

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Additional comments

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