Student Dependent Declaration Form

Student First Name

Membership #

I declare that:

The dependent will not be registered as a full-time student by 1 March 2025. However the dependent is a participant, with an active plan, in the National Disability Insurance Scheme (NDIS) and you request to keep the dependent covered under the policy (evidence of their active NDIS plan is required upon application of this cover ^)

^ Where the requested evidence is not provided, the dependent will not be eligible to be covered under your policy.

Our Member Services Team will provide written confirmation of any changes or updates.

Please provide any other information that may assist.

The statements made and information provided are true, correct and complete; and

I undertake to inform Police Health immediately of any change in the circumstances of the above-named dependent; and

I have read and understand Police Health privacy notice.

Full Name of Person Completing Form

Date

Option 3 - Other Dependent Person Options