GENERAL DECLARATION

Police Health Plan Ltd is a member of Health Funds Association of New Zealand (HFANZ). On behalf of its members, HFANZ manages an Integrity Registry for the purposes of detecting and preventing fraud and other serious probity concerns. The Integrity Registry is operated by PricewaterhouseCoopers. Police Health Plan Ltd may collect, use and disclose personal and health information about you for the purposes of the Integrity Registry. You can access and correct information held on the Integrity Registry. Contact Police Health Plan Ltd or HFANZ Integrity Registry Privacy Officer, Health Funds Association of New Zealand, PO Box 25161, Wellington 6146.

• 1. I declare that:
• 1.1 All entries on this form are true and correct;
• 1.2 Any false answer may forfeit all right to any benefits from Police Health Plan Limited (Health Plan).

• 2. I agree:
• 2.1 to be bound by Health Plan Rules; and
• 2.2 that the information may be exchanged between Health Plan, NZ Police Association, Police Welfare Fund Limited and associated bodies (including Police Welfare Insurances Ltd, General Insurances Ltd and Police Welfare Fund Mortgages Ltd) for providing information on services and statistical, processing and underwriting purposes.

• 3. I understand that:
• 3.1 if I have agreed to take advantage of a discounted premium by selecting a voluntary excess, I agree to pay this excess amount towards any surgical procedures I may require.
• 3.2 if I select a voluntary excess and then choose to switch to a lower or no-excess option, a 90-day stand-down period will apply before the lower or no-excess option commences, and all conditions that were existing under the previous higher voluntary excess, will still incur that excess, regardless of when any procedure on this condition is carried out.

• 4. I authorise Health Plan to seek any further medical information as and when required.

• 5. I confirm I have read the Police Heath Plan Limited Rules (August 2017) and that I agree to be bound by the plan rules, terms and conditions.

• 6. I confirm that the Police Health Plan Limited, or any employee thereof, has not provided me with personalised financial advice other than general information about the Police Health Plan.

READ AND ACCEPT TERMS AND CONDITIONS FOR MEMBERSHIP OF NEW ZEALAND POLICE ASSOCIATION AND POLICE WELFARE FUND LIMITED

I apply for membership of the New Zealand Police Association (NZPA)/Police Welfare Fund Limited and declare the information in this application is true and correct.

RULE COMPLIANCE AND SUBSCRIPTION PAYMENTS

• 1 I agree to:
• 1.1 Abide by the Rules, as amended from time to time, of the NZPA and Police Welfare Fund Limited (including Police Welfare Fund Insurances Ltd, Police Welfare Fund General Insurances Ltd, Police Health Plan Ltd and Police Welfare Fund Mortgages Ltd).
• 1.2 Pay any subscriptions or fees pursuant to my membership when they are due.
• 1.3 The NZPA and Police Welfare Fund Limited commencing subscription deductions from my salary following graduation from the Royal New Zealand Police College or 6 months after entering the RNZPC, whichever is the lesser, provided that I have not notified the Police Welfare Fund Limited or NZPA, in writing, of my intentions to cease membership.
• 1.4 The NZPA and Police Welfare Fund Limited altering my subscription deductions from my salary following notice of subscription changes and/or amendments to fees for products and services I have purchased.

REPRESENTATION

• 2 Pursuant to the rules and policies of the NZPA, I authorise them to act as my representative in matters relating to my employment, including but not limited to:
• 2.1 The negotiation and enforcement of (an) employment agreement(s)/contract(s), whether individual or collective;
• 2.2 Consultation on any matter or policy which may, or is likely to, impact on my employment; 2.3 Any proceedings related to my employment;
• 2.4 Receiving personal information about me from my employer, including receiving information prior to that information being conveyed to me (e.g. any pending disciplinary allegations and investigation).

• 3 In the event that there is a legal issue arising from my employment, I understand and agree that, in accordance with it’s rules and policy, NZPA will make the final determination in respect to the progression and NZPA representation of that issue.

• 4 I agree with the following ratification procedure for any collective employment agreement contract(s) which the NZPA may negotiate on my behalf: the proposed settlement will be accepted if supported by the majority of votes cast in accordance with the NZPA Rules by those relevant eligible members of the NZPA voting for the purpose of ratifying a settlement.

• 5 I understand I can withdraw my authorisation to be represented by the NZPA prior to any proposed settlement being reached in negotiations with my employer for a collective employment agreement/contract; or with regard to any other matter at any stage.

PRIVACY ACT CONDITIONS

• 6 I agree that the information in this application may be used by all of the bodies I have applied for membership of and any third party in providing additional related or unrelated services to me.

• 7 I authorise any person or company to provide the bodies in condition 1, including Police Welfare Fund Insurances Ltd, Police Welfare Fund General Insurances Ltd, Police Health Plan Ltd and Police Welfare Fund Mortgages Ltd, with any information requested by them in connection with any services provided by the bodies, or the Police Credit Union (PCU).

• 8 I acknowledge that:
• 8.1 The information now given in my application or supplemented at any future time is being collected in connection with my membership of and the provision of services by the bodies referred to in condition 1 and, if applicable, the PCU;
• 8.2 That information and any supplement to it may be exchanged between the bodies referred to in condition 1 or the PCU without any further authority from me; and
• 8.3 The information will be held by those bodies and, if applicable, the PCU, subject to my rights of access to, and correction of, that information as provided in the Privacy Act 1993.