Refund Request Form

Agent - Refund Request Form

Name
Date of birth
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Address
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Original payment method
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Payment Date

Credit Card

Credit card refunds must be processed back to the original credit card used to purchase or amend your nib OSHC policy. Please provide the details below. If the original credit card used to purchase your nib OSHC is no longer valid/active, you must receive your refund to an Australian or overseas bank account. Please note: If the credit card isn't in your name, then you will need to contact the owner to organise reimbursement.
Expiry Date
Card Type

Payment originally made through flywire and refund to be processed via flywire

Refund will be processed to original credit card or bank account.

Deposit into Australian Bank Account

Deposit into An International Bank Account

Account Holder's Street Address Including City/State/Prov/Zip Code (No PO Boxes)
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Please select currency
You must select a currency and confirm it is accepted by your Bank/Financial Institution before applying for your refund.
Bank/Financial Institution Street Address Including City/State/Prov/Zip Code/PO Box
I declare that the information declared on this form is complete and correct. I agree to the conditions of this refund and declare that I am the person to whom this refund is to be paid.
Clear Signature
Date
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