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 enter your contact information

Name(*)

Please enter the contact's name.

Organisation(*)

Please enter the organisation's name.

Phone(*)

Please enter the contact's phone number.

Email(*)

Please enter the contact's email address.

Member details

First name(*)

Please enter the member's first name.

Last name(*)

Please enter the member's last name.

Address(*)

Please enter the member's address.

Suburb(*)

Please enter the member's suburb.

Postcode(*)

Please enter the member's postcode.

Phone(*)

Please enter the member's phone number.

Email(*)

Please enter the member's email address.

Date of birth(*)

Please select the member's date of birth.

Select your membership option

All memberships include access to the gym, group fitness and aquatic facilities.(*)

3 months Multi Access $487.00 Please select an option.

Invoicing details

Organisation to invoice(*)

Please enter the organisation's name.

Contact person(*)

Please enter the invoicing contact's name.

Address(*)

Please enter the invoicing address.

Suburb(*)

Please enter the invoicing suburb.

Postcode(*)

Please enter the invoicing postcode.

Phone(*)

Please enter the invoicing phone number.

Email(*)

Please enter the invoicing email address.

Claim number(*)

Please enter your claim number.

Membership start date

Select the start date(*)

Please select the start date

Supporting Documentation

If you have any supporting documentation, please upload.

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Additional comments

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