Experience NZ Insurance

Apply Online

1 Applicant Details
2 Other Applicants
3 Cover Details
4 Summary & Payment

Please complete the form below in English

Step 1 – Applicant Details

Family Name *

First or Given Name *

Date of Birth *

/ /

Gender*

Country of origin *

Phone Number *

Email Address *

Confirm Email Address *

Agent Email Address (optional)

Type of Visa *

Are you new OrbitProtect policy holder? *

How did you hear about us? *

Please complete the form below in English

Step 2 – Other applicant details

Fill in the details of other applicants included in this application.

Spouse

Family Name

First or Given Name

Date of Birth

/ /

Gender

Dependants

Number of dependants to include in this policy

Dependant 1

Family Name

First or Given Name

Date of Birth

/ /

Gender

Dependant 2

Family Name

First or Given Name

Date of Birth

/ /

Gender

Dependant 3

Family Name

First or Given Name

Date of Birth

/ /

Gender

Dependant 4

Family Name

First or Given Name

Date of Birth

/ /

Gender

Dependant 5

Family Name

First or Given Name

Date of Birth

/ /

Gender

Dependant 6

Family Name

First or Given Name

Date of Birth

/ /

Gender

Please complete the form below in English

Step 3 – Cover Options

Make a selection below

Prime Family

Medical care + medical evacuation + loss of deposits + property (NZ$2,500 per item, pairs or sets of items and max total value of NZ$10,000).

Lite Family

Medical care + medical evacuation + loss of deposits

Prime Individual

Medical care + medical evacuation + loss of deposits + property (NZ$2,500 per item, pairs or sets of items and max total value of NZ$10,000).

Lite Individual

Medical care + medical evacuation + loss of deposits

Not sure which option you want? The Experience NZ Brochure explains the difference between Lite and Prime.

Specified items cover

Check this box if you want to specify items to be insured.

You have indicated you would like to specify items to be insured, our customer service officers will contact you to discuss with you the item(s) you can insure. Please note, additional premiums apply for this special cover.

Experience NZ Prime AUTOMATICALLY covers property up to NZ$10,000. Experience NZ Lite does not provide automatic property cover. Alternatively, you can choose to specify the items you want to insure.

Additional Options

Manual Work Cover for dairy farming, building and related trades cover

Not selected

Additional information


Do you have any pre-existing medical conditions?

A pre-existing condition is any medical or physical condition or circumstance that you are aware of, or ought to be aware of, that you have before the start date of the insurance. Remember: any existing condition (Asthma, Acne as examples) that may not have been active prior to the insurance start date that reoccurs after the start date will NOT be covered.

Declaration confirmed

I agree to be bound by the OrbitProtect Experience NZ insurance Policy Wording (Lite or Prime as selected) and the Terms of Sale.

Please complete the form below in English

Step 3a – Medical conditions: Additional information

1. Are you currently suffering from a medical condition, illness or injury?

2. Have you been admitted to hospital in the past 12 months?

3. Are you currently taking any medication?

4. Have you ever received treatment for any type of:

Heart Ailment

Circulatory conditions

Cancer, or

Back or spinal problems

Additional information

Please describe your medical condition:

What medication or treatment has been prescribed to treat your medical condition?

What is your doctor's name?

What date did you last visit your doctor?

What is your doctor's address?

Please note: There is a non-refundable one-off fee of $45.00 NZD for the assessment irrespective of the outcome.

Your application for Experience NZ Insurance

Policy Summary

Total Premium

$ NZD

Insured


Spouse


Children


Country of origin


Phone


Email



Start date


End Date

Medical Conditions Warning

Medical Conditions Assessment Fee

$45.00 NZD

Your pre-exisiting medical conditions are not automatically covered under the Policy. Your application will be referred to our OrbitProtect team for assessment. Our Customer Service Officer will contact you. You will be notified in writing of the outcome of the assessment.

Underwriting Review

You are currently under underwriting review. Your application will be referred to our OrbitProtect team. Our Customer Service Officer will contact you. You will be notified in writing of the outcome of the assessment.

Please note that you are not insured until the premium has been paid in full.

High value items

You have indicated you would like to specify items to be insured, our customer service officers will contact you to discuss with you the item(s) you can insure. Please note, additional premiums apply for this special cover.

Select Payment Method

Credit Card

Pay instantly and securely online with your Credit Card via Payment Express.

Offline Payment via NZ Bank Transfer

An invoice with payment instructions will be sent to your email address


Offline Payment Warning

In order to make payment into our bank account in New Zealand:

  • You MUST have a New Zealand bank account if you are making payment through the internet.
  • You MUST be able to go to a Westpac Bank in New Zealand to deposit cash in to our bank account.

Offline Payment

Reference Number


Invoice and Payment instructions

An invoice with payment instructions has been sent to your email address.


View invoice

Credit Card Payment

Reference Number


You may now proceed with your online payment.

Blog

GP vs After-Hours Clinic vs Hospital

GP vs After-Hours Clinic vs Hospital

Good on you for securing yourself with an OrbitProtect policy! What now? How and when do you use it? Where do you go? Do you need approval to see a doctor? Does the doctor need to be affiliated with OrbitProtect? We know it is daunting enough to be in a...

Read More
16/08/2020
CORONAVIRUS: IMPORTANT INFORMATION click here