Medical Declaration

    Your Details

    Pre-Existing Conditions

    Pre-Existing conditions are not automatically covered under your policy. A pre-existing condition is any medical, dental, mental or physical condition or circumstance which you are aware of or ought to be aware of prior to the start date of your policy. Pre-existing conditions that you do not tell us about, or do not seek cover for, will be excluded under your policy. Further Information

    General Health Questions:

    Have You:

    Are You:


    I have read and retained a copy of the Policy Wording. I consent to the collection, use and disclosure of my health and other personal information for the purposes outlined in the Privacy section of the Policy Wording. I agree that I will not be covered for any Existing Medical Condition unless the insurance company has agreed to insure those conditions. I agree that cover will not include replacement medication or maintaining a course of treatment commenced before the trip. I understand that should cover be given for any Existing Medical Condition, it will be for UNEXPECTED TREATMENT ONLY. I declare the answers given are true and accurate, and I consent to my doctor/medical provider releasing my medical history to nib nz limited. I understand that should my health change prior to the journey commencing, I must inform the company who may impose special terms and conditions. I understand that if I don’t provide all information requested nib may not be able to assess my application and provide me with the requested insurance.

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