BENEFIT FUND APPLICATION FORM /
AMBULANCE BENEFIT FUND APPLICATION FORM
(7 DAY QUALIFYING PERIOD)
$119.00 / Per annum for a family (An individual plus spouse/partner and dependent children up to the age of 18)
$72.00 / Per annum for a single / Joining Date: / /
APPLICATION DETAILS
MR MRS MISS MS OTHER
SURNAME:
GIVEN NAMES:
DATE OF BIRTH:
ADDRESS:
POST CODE
PHONE:
COVER REQUIRED
Cover (tick one) SINGLE OR FAMILY (Please complete details below of other persons to be covered)
SURNAME / GIVEN NAMES / DATE OF BIRTH
**PTO FOR TERMS AND CONDITIONS
PAYMENT DETAILS
I enclosed my cheque/money order (name and address on back)
Please debit my / MasterCard / Visa
CARD NUMBER CARD EXPIRY: /
CARD HOLDERS NAME (IN CAPITALS): CCV (back of card):
CARD HOLDER’S SIGNATURE:
SEND YOUR COMPLETED APPLICATION AND PAYMENT TO YOUR LOCAL ST JOHN AMBULANCE CENTRE
Please email the completed form to
Post: 270 Bussell Highway, Bunbury WA 6230 or Fax (08) 9791 3295
For further information, please contact our Administration Team on Phone (08) 9791 4999
HOW DO I JOIN?
Simply complete the application form and select your method of payment, either by cash, cheque,
Credit card or you can also join over the phone by calling your local St John Centre (08) 97914999
Drop the completed form and payment at the Bunbury St John Ambulance centre, or post to:
St John Ambulance
270 Bussell Highway, Bunbury WA 6230
Or email to:
Alternatively you can submit your completed form and payment to one of the following locations:
• Australind Village Pharmacy – Australind Shopping Centre
• Collie Chemmart Pharmacy
• Eaton Community Pharmacy ‐ Corner Old Coast and Pratt Road (Next to Caltex service station)
A membership card will be issued within 14 days. If after your 7 day qualifying period you require ambulance
Transport; and you receive an account, simply write your membership number on the account and return with nothing to pay.
St John Country Ambulance Benefit Fund Cover
TERMS AND CONDITIONS:
1. Your subscription covers ambulance to patients in the following categories:
(i) Emergency: People who are seriously ill or severely injured. No authorisation necessary for those
journeys.
(ii) Non‐emergency: People who need medical/surgical convalescent stretcher transport. The local St
John Ambulance sub centre will certify that the ambulance transport was ‘justifiable’.
2. St John Country Ambulance Cover is designed to safeguard every member of the family as well as
individuals. Family Membership covers your spouse/partner and all dependent children until they turn 18.
3. Membership is not transferable or refundable.
4. Benefit is not payable if the patient has a right to claim fees from another person as damages or under
Third Party Insurance, Workers’ Compensation or other statutory provisions.
5. The cover is restricted to ambulance Transport provided by St John Ambulance Western Australia and
road ambulance services in other states.
6. A Member is deemed un‐financial immediately following expiry date. Renewal notices are mailed
approximately one month prior to ensure address details are correct and the contribution is paid by the
due date.
7. The qualifying period is 7 days from receipt of application.
8. St John Ambulance reserves the right to cancel membership, or refuse renewal of membership if the
subscriber is found to be abusing the service by misuse of unauthorised transport.
The information collected is for the use by St John Ambulance and will not be passed on to third parties.
Our Privacy Policy may be viewed online at www.stjohnambulance.com.au or to access information please
contact our Privacy Officer on 9334 1222.
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