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Accident Recovery Insurance - Purchase
Please complete all fields marked
*
How did you hear about us?
-Select-
AA Life Website
AA Website
Google
Yellow or White Pages
TV
Other
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Please specify:
Your Details
Title:
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Mr
Mrs
Miss
Ms
Dr
Rev
Other
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First names:
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Last name:
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My date of birth:
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Year
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Address:
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Suburb:
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Town/City:
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Postcode:
Home Telephone:
Work Telephone:
Mobile Telephone:
Email:
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AA Membership
Are you an AA Member?:
Yes
No
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AA Membership Number:
*
Plan Selection
Select your plan:
Superior - $32.65 a month
Standard - $20.55 a month
Superior - $31.02 a month
Standard - $19.52 a month
How do you want to pay?
Payment Method:
EasyPay
Direct Debit or Credit Card online
EasyPay payment options:
Credit Card online
Direct Debit online
Credit Card Details
Card type:
-Select-
Visa
MasterCard
American Express
Diners Card
*
Cardholder's Name:
*
Card Number:
(Please do not use any spaces)
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Expiry Date:
Month
08
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01
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Year
2010
2011
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2014
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Direct Debit Online Details
Do you have individual signing authority on the chosen account?
Yes
No
*
Unfortunately we are unable to offer Direct Debit EasyPay where two or more signatures are required on your chosen bank account.
Please use an account that you do have individual signing authority on, or choose a different method of payment.
Account Number:
Bank
Branch
Account
Suffix
*
Name of Account:
*
Other payment options:
Direct Debit Authority
Cheque
Direct Debit Details
I will download a Direct Debit form here:
Direct Debit Form
Please send me a Direct Debit form.
Cheque Details
Cheques can only be accepted for quarterly, half yearly and yearly premium payments.
Please make your cheque payable to Asteron Life Limited. Print your name, address and phone number on the back and send it freepost to:
AA Life
Freepost 198921
PO Box 3369
Wellington.
Payment Frequency:
Monthly
Quarterly
Half Yearly
Annually
Your Agreement
I understand that my cover will commence as soon as my fully completed Application Form is accepted by Asteron Life Ltd, and they may obtain information from any doctor, hospital, health agency, insurance officer or any other person or entity, required for the purpose of assessing my application and any claim in relation to this insurance and I authorise such information to be released to Asteron.
I also understand the information on this form will be held by Asteron and by The New Zealand Automobile Association Incorporated and its related companies (NZAA), and that the information may from time to time be used to send me details of other products and services.
I am aware that under the Privacy Act 1993 I have certain rights to request access to and correction of information held by Asteron and AA Life Services Ltd. If I have elected to pay premiums by Credit Card, I authorise Asteron to charge the nominated account for all premiums required under the cover.
I have read and agree to the terms above
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