Application to vary income protection cover
|
|
- Dennis Warren
- 8 years ago
- Views:
Transcription
1 Application to vary income protection cover Before completing this application please read the Insurance Handbook for Sole Traders at Duty of disclosure Before you enter into a contract of life insurance with an Insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the Insurer every matter that you know, or could be reasonably expected to know, that is relevant to the Insurer s decision whether to accept the risk of insurance and if so, on what terms. You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of life insurance. Your duty, however, does not require disclosure of a matter that diminishes the risk to be undertaken by the Insurer; that is of common knowledge; that the Insurer knows, or in the ordinary course of its business ought to know; as to which compliance with your duty is waived by the Insurer. Non-disclosure If you fail to comply with your duty of disclosure and the Insurer would not have entered into the contract on any terms if the failure had not occurred, the Insurer may avoid the contract within three years of entering into it. If your non-disclosure is fraudulent, the Insurer may avoid the contract at any time. An Insurer who is entitled to avoid a contract of life insurance may, within three years of entering into it, elect not to avoid it but to reduce the sum that you have been insured for in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to the Insurer. section 1 Personal details THIS STEP MUST BE COMPLETED in Full Please use CAPITAL letters and cross appropriate boxes Member number Title X Mr X Mrs X Miss X Ms X Other Date of birth D D M M Y Y Y Y Male X Female X First name(s) Family name Telephone (home) ( ) Telephone (mobile) Address Unit number Street number Street name Suburb/town State/Territory Postcode Your employment status Sole Trader Unincorporated Partnership Occupation Duties performed section 2 Increasing, varying or upgrading your Income Protection Cover By completing the application form, you have the opportunity to: Upgrade your Accident-only Income Protection cover to Accident and Illness cover. This will provide you with cover for both an Accident or Illness which first occurs after your cover commences Increase your units of cover for Accident-only cover or Accident and Illness cover to provide you with a greater monthly benefit (subject to the limits outlined in the Insurance Handbook for Sole Traders on page 19). Vary your waiting period from 30 days to 90 days Vary your benefit period from two years to five years You MUST fully complete all sections of this Application to vary income protection cover including Section 3 Personal Information if you are applying to upgrade to Accident and Illness cover, increase your number of units of cover, vary your benefit period to five years or alter your waiting period from 90 days to 30 days. If you are ONLY applying to vary your waiting period from 30 days to 90 days, please nominate this change in question 4 below and sign and date Section 5-Declaration. 1. Select one of the following options: X I wish to upgrade my Accident-only Income Protection cover or X I wish to increase the number of Accident-only units of cover to Accident and Illness cover 2. Provide your current Annual Taxable Income (ie. Your annual income for the last financial year before tax, but after business expenses were deducted) $ 3. How many units of either Accident and Illness cover or Accident- only cover do you wish to apply for (this should be the total number of units you require, as this will replace any existing units you may already have) Read page 19 of the Insurance Handbook for Sole Traders to help you calculate the number of units you need. The number of units you choose should not exceed the number needed to provide you with a benefit of 85 per cent of your Annual Taxable Income (rounded up to the next whole unit). 4. Choose your waiting period 30 days X 90 days X Your Income Protection cover will be provided with a standard waiting period of 30 days. However, you may choose to increase your waiting period to 90 days. This will reduce the cost of your cover, however if you claim you will not start to be paid disability benefits until you have been disabled for a continuous period of at least 90 days. If you do not choose a waiting period, a 30-day waiting period will automatically apply. 5. Choose your benefit payment period 2 Years X 5 Years X Your Income Protection cover will be provided with a standard benefit period of two years. However, you may choose to increase your benefit period to five years. If you do not indicate a benefit period, a two-year benefit period will automatically apply. Note: you can cancel or decrease your level of Income Protection cover at any time by completing an Application to decrease or cancel insurance cover form at If you wish to reapply at a later date, your cover will be subject to acceptance by the Insurer and Cbus. Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN AFSL Cbus ABN /13 Page 1 of 6
2 section 3 Personal information Section 3 must be completed in full This information will be treated in strict confidence and will be used or disclosed only for matters relating to your insurance entitlements. 1. What is your height? cm or; feet inches and weight? kg or stone pounds 2. Have you ever been paid, entitled to receive, or are presently applying for a TPD or Terminal Illness Benefit from any superannuation arrangement or any insurance policy? If you answer Yes to this question, your insurance may be affected. (Members who are eligible to receive or have ever been paid a Total and Permanent Disability Benefit (TPD) from any superannuation fund or insurance policy are not eligible to apply for Income Protection cover). Please indicate in the space at the end of this section when the claim was submitted, the type and cause of claim and outcome. 3. In the last 12 months, have you smoked tobacco in any form? If Yes please state form and daily quantity 4. Have you lost the sight of an eye(s) or the use of a limb(s) (limb includes the whole hand or foot), or do you have any defect of hearing? 5. To your knowledge, have you suffered from: (a) diabetes, epilepsy, multiple sclerosis, hepatitis B or C? (b) asthma or any other respiratory disorder (other than the common cold)? (c) chest pain, high blood pressure, heart complaint, paralysis, stroke, cancer or tumour of any type? (d) disease or complaint related to kidney, bladder, lung, bowel, liver, stomach or any blood disorder? (e) mental or nervous disorder or chronic fatigue syndrome? (f) any disease or injury to the neck, back, RSI or arthritis? (g) AIDS, AIDS-related complex, AIDS-related condition, or have you ever had a test for HIV (Human Immunodeficiency Virus) antibodies which has proven positive? If you have answered YES to any of the above questions, please provide details below: (a) nature of condition/complaint (b) date commenced (c) duration of injury/illness (d) time off work (e) details of any operation performed (f) degree of recovery (g) names and addresses of doctor(s) or hospital(s) consulted If you need more space for your response, please attach an additional page. 1. MEMBER INSURANCE HISTORY 1. Has Life, Disability, Accident and Sickness or Superannuation cover on your life ever been declined, deferred or withdrawn from any insurance company or accepted with a loading, exclusion or other than as applied? > Please provide full details (including dates, name of company and reason) 2. Have you ever made a claim for disability benefits under an Insurance, Superannuation or Worker s Compensation policy, Veteran s Affairs or under Social Security (including CTP and public liability)? > Please provide full details (including dates, cause of claim, type of benefit and amount paid, claim number and insurance company) 3. Other than this application, do you have or are you applying for any Life, TPD, Disability Income, Income Protection or Group Salary Continuance (GSC) with any other company? > Please provide full details Company Type of Policy Benefit Amount Owner To be replaced by this policy No Yes No No Yes Yes Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN AFSL Cbus ABN /13 Page 2 of 6
3 2. HABITS, ACTIVITIES AND RESIDENCE 1. Do you drink alcohol? > Please state type and weekly quantity 2. Do you currently, or do you intend to engage in any hazardous pastime and/or sporting activity such as aviation (other than as a fare paying passenger on a recognised airline), motor racing of any kind, diving, football, parachuting, hang gliding, etc? > Please provide full details 3. Are you an Australian Resident (as defined in Insurance definitions on pages of the Insurance Handbook for Sole Traders)? If you answer no, please provide details below: 4. Do you intend travelling overseas in the immediate future (i.e. next 2 years?) > Please give full details (where, when, duration and reason) 3. MEDICAL STATEMENT 1. Name and address of your Doctor Telephone ( ) 2. How long have you been a patient of this doctor? Years Months 3. Details of last medical consultation, including doctors, physiotherapists, chiropractors or ANY other health professional. Date Health Professional Address Reason Outcome/Result 4. Within the LAST THREE YEARS have you, other than advised previously: a. Consulted, been examined or treated by, or received advice from any doctor, psychologist, psychiatrist, counsellor, chiropractor, physiotherapist or other health care professional (naturopath, etc) or been in a hospital or been advised to have an operation? b. Either occasionally or regularly taken any drugs, stimulants, sedatives, tranquillisers, medications by mouth, by inhalation or by injection? 5. Have you EVER had an ECG, x-ray, transfusion, mammogram, surgery or any other investigation? 6. Have you EVER had any blood tests which revealed an abnormality, eg raised blood sugar, liver function or renal function results, or anaemia, etc? 7. Do you contemplate seeking any medical examination, advice, treatment or surgery in the future? Please provide full details for all YES answers below (if more space is required, please fill in the additional information at the end of this section. Dates From: To: Name and address of Doctor or Hospital, Clinic, etc Conditions, Medications Treatment and Time off Work Recovery % Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN AFSL Cbus ABN /13 Page 3 of 6
4 8. Have you EVER received any advice or treatment for: a. raised cholesterol, or circulatory disorder? b. shortness of breath, palpitations, or rheumatic fever? c. bronchitis? d. indigestion, hernia, gastric or duodenal ulcer, colitis or any other intestinal disorder? e. gall bladder disease? f. knee complaint or any disorder of the joints, bones or muscles (eg. gout, arthritis)? g. renal colic, stones or blood in the urine? h. depression, anxiety, or stress? i. melanoma, sunspots or growth of any kind? j. eczema, dermatitis, psoriasis or any other skin condition? k. tinnitus, hearing loss or any defect in hearing, sight or speech? l. anaemia, leukaemia, or haemophilia? m. thyroid or prostate disorder, any disorder of the reproductive organs, or sexually transmitted disease? n. persistent diarrhoea, unexplained weight loss, enlarged lymph glands, recurrent fever or night sweats? o. fits of any kind, recurrent headaches, dizzy spells or fainting attacks? p. any other physical impairment, congenital abnormality, deformity or symptoms of ill health, illness or injury? Females only q. Have you ever had any gynaecological conditions (eg endometriosis, abnormal pap smear, etc)? r. Have you ever had any complications of pregnancy or childbirth? s. Are you currently pregnant? If yes, what is the expected delivery date? D D M M Y Y Y Y t. Have you ever had a breast lump (even if you have not seen a doctor about it)? Please provide full details for all YES answers below (if more space is required, please fill in the additional information at the end of this section. Specific Condition Question Number Question Number Question Number 1. Date symptoms first started and description of symptoms 2. What was the condition and which part of the body was affected? 3. What was the medical diagnosis including results of x-rays and investigations? 4. What was the frequency (daily, weekly, etc) of attacks or symptoms? 5. What was the severity (mild/moderate/ severe) and duration of attacks or symptoms? 6. How long were you unable to work or perform your normal duties/activities? 7. If a hospital visit was required, please provide date and duration of your stay 8. What advice/treatment did you receive? 9. Are you still receiving treatment? If so, please advise nature and frequency of treatment. 10. When did you last suffer from any symptoms? 11. Degree of recovery (%) 12. Please supply name and address of all doctors or hospitals or other consultants Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN AFSL Cbus ABN /13 Page 4 of 6
5 4. FAMILY HISTORY Please cross No or Yes Does or has any member of your immediate family [father, mother, brother, sister] suffered from: Huntington s disease; or Polycystic kidney disease; or Familial adenomatous polyposis; or Muscular dystrophy; or Motor neurone disease; or Cystic fibrosis or any other hereditary disorder? If YES, state the name of the disease or disorder and the relationship of the family member: 5. QUESTIONS IN RELATION TO AIDS 1. Have you EVER been infected by the virus which causes AIDS (the Human Immunodeficiency Virus)? 2. Have you EVER sought or are expecting to receive treatment for AIDS or an AIDS related condition or have you ever had a positive test for HIV? 3. Have you EVER shared a needle or syringe for the injection of any drug, engaged in male to male anal sexual activity or worked as or engaged in sexual activity with a prostitute or someone you know or suspect to be HIV positive? NB if any of these questions are answered yes, we will send you a separate questionnaire. 6. OCCUPATION DETAILS 1. Do you trade in your own right as a Sole Trader or in an Unincorporated Partnership in which you and/your partners bear full personal responsibility for all of your business actions and liabilities? 2. Has your business been established to exclusively provide services to one client or organisation? 3. Has your business been established under a company structure and are you a shareholder, director or employee of that company? 4. For your primary occupation, are you eligible to receive Superannuation Guarantee contributions into Cbus or any other superannuation fund? 5. Do you work either full time or part time in an excluded occupation? (Refer to page 34 of the Insurance definitions section of the Insurance Handbook for Sole Traders.) Please provide full details of your self-employed business: How long have you operated this business? years months Percentage of business you own % Name of business Address of business How many employees do you have? (excluding yourself) How many hours per week do you work? 6. What are the main duties of your occupation? Postcode Duties (eg, office work, sales, supervision, manual) % of time 7. Have you completed an apprenticeship or do you hold an Australian Recognised Trade Certificate or a degree in the field in which you are working? > Please provide full details Type Name of institution where obtained Please note: The Insurer will determine your occupational status of manual, skilled trades or non-manual. 7. FINANCIAL DETAILS Please note that based on the financial information provided below, additional financial information may be needed. 1. If disabled, would all or part of your income continue? (eg other disability income policies, pension, investment, rental, company profit share, etc) > Please provide full details Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN AFSL Cbus ABN /13 Page 5 of 6
6 7. FINANCIAL DETAILS (continued) 2. Income details for the last two financial years: self-employed only (ie, sole trader or partner within an unincorporated partnership) Annual Amounts Year ended 30/06/20 Year ended 30/06/20 Gross income from business Less ALL business expenses Net income/profit before tax Your share of net income Add back: Any personal wages, salary Allowances (eg, car) Superannuation Payments to spouse (income splitting only) Other (eg, your share of depreciation, your share of profit from supporting service company/trust please specify) TOTAL NET EARNED INCOME NB - any amounts received as wages/salary/drawings/ must not be paid from past profits, capital or loans. 8. ADDITIONAL INFORMATION (to help clarify any issue) section 4 Doctor s authority For the purposes of assessing my eligibility for insurance, I authorise my current medical practitioner, and any other medical practitioner or health professional I have consulted or may consult in the future, or that Hannover Life Re of Australasia Ltd (HLRA) appoints to examine me, to disclose information about my health and related matters to HLRA. A photocopy of this authorisation will be as valid as the original. MEMBER S Signature X D D M M Y Y Y Y section 5 Declaration Declaration To be completed by ALL applicants I declare the answers I have provided in this Application to vary income protection cover form are true and correct and that I have not deliberately withheld any information. I acknowledge this declaration is part of an application for Income Protection and that making a false statement may invalidate my application. I also acknowledge that I have read the duty of disclosure and consequences of non-disclosure. I understand the information on this form will be reviewed by Cbus for the purpose of assessing my eligibility for increased insurance cover and it will be forwarded to the Insurer for further review. I acknowledge any variation in my insurance cover will not start until accepted by the Insurer. I acknowledge my entitlement for an insured benefit under Cbus is subject to the terms and conditions of the Fund s insurance policy. Furthermore: I understand that in order to assess and process my application, Cbus or its Insurer may need health and employment information about me. I consent to Cbus or its Insurer obtaining information about me from any medical practitioner or health professional that I have or may consult in the future, or that Cbus or its Insurer appoints to examine me. I understand if I or anyone else on my behalf makes a claim for a benefit, Cbus and the Insurer will need information about me in order to assess and process the claim. For this purpose, I hereby consent to Cbus or the Insurer obtaining information about me from any of the following: Medical practitioners that I have consulted at any time, any that Cbus or the Insurer wishes to appoint to examine me, legal practitioners, health service providers, legal tribunals and courts, investigation organisations or other consultants, other insurance or reinsurance companies, my past and present employers and interpreters. I understand I am only eligible to receive insurance cover under one Cbus account. For the purpose of this application and any claim for a benefit, I also consent to Cbus or the Insurer disclosing information about me to any of the organisations mentioned above, insofar as such disclosure is necessary for Cbus or its Insurer to perform its functions. I have read and carefully considered this declaration and the questions on this Personal Health Statement and I confirm that all the statements are true and correct in relation to me. X D D M M Y Y Y Y Note: this form must be received by Cbus no later than 31 days from the date you complete, date and sign it. Please send this completed form to: Cbus, Locked Bag 999, Carlton South, VIC 3053 Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN AFSL Cbus ABN /13 Page 6 of 6
Insurance Application / Personal Statement
Insurance Application / Personal Statement IMPORTANT NOTICES PLEASE READ Privacy The Privacy Act 1988 ( the Act ) sets out a number of principles that we must comply with in the collection, security, storage,
More informationPERSONAL STATEMENT IMPORTANT NOTICES - PLEASE READ
PERSONAL STATEMENT Please return this form to: NESS Super Locked Bag 20 Parramatta, NSW, 2124 Duty of Disclosure IMPORTANT NOTICES - PLEASE READ Before you enter into a contract of life insurance with
More informationvoluntary insurance application
voluntary insurance application All members may apply for AvSuper voluntary insurance cover, although some age restrictions apply. Please refer to the AvSuper member insurance guide for details of cover.
More informationAdditional voluntary insurance cover
SA Metropolitan Fire Service Superannuation Scheme Additional voluntary insurance cover About this form Complete this form if you wish to increase or decrease the level of additional insurance cover provided
More informationIncome Protection, Life and Total and Permanent Disablement Insurance for Avant doctors Application Form
Income Protection, Life and Total and Permanent Disablement Insurance for Avant doctors Application Form Avant Mutual Group Limited ABN 58 123 154 898 This is an application form for income protection,
More informationPersonal Statement (Full)
WELCOME Personal Statement (Full) How to use this form Complete this form if you are applying for top-up death and Total & Permanent Disablement (TPD) cover over $500,000 (inclusive of any existing base
More informationPersonal Statement/ Member s Statement
Personal Statement/ Member s Statement Group Life including Income Protection Policy Ref No. MP9926 Member ID: Employer Name: Disclosure Notice Your duty of disclosure Before you enter into a contract
More informationInsurance Request Form
Insurance Request Form SuperSolution Master Trust and RiQ Super Use this form to request new insurance, make a change to your existing insurance cover and/or occupation category. Print clearly in BLOCK
More informationComplete this form if you want to apply for or increase your Income Protection insurance cover. Suburb/City/Town State/Territory Postcode
Member Details form Member Income Protection Form w Complete this form if you want to apply for or increase your Income Protection insurance cover. Income Protection insurance cover, also known as salary
More informationBendigo SmartStart Super Insurance Application and Personal Health Statement Form
Bendigo SmartStart Super Insurance Application and Personal Health Statement Form You should use this form if you wish to apply for Tailored Cover or increase your existing Tailored Cover. Your duty of
More informationFull Personal Statement
Full Personal Statement Policy Ref No. (Office use only) SMSF Master Insurance Plan SMSF Provider Code: Member No: (Office use only) Disclosure Notice Your Duty of Disclosure Before you enter into a contract
More informationAPPLICATION FOR BUPA INCOME PROTECTION
APPLICATION FOR BUPA INCOME PROTECTION This application relates to the Combined Product Disclosure Statement and Financial Services Guide dated 28 October 2011. Please do not complete this application
More informationHow To Get A Life Insurance Policy From Aia Australia
Personal Statement/ Member s Declaration Group Life including Salary Continuance Issued March 2004 Member ID: Employer Name: Disclosure Notice Your duty of disclosure Before you enter into a contract of
More informationApplication for insurance cover form and personal health statement
Application for insurance cover form and personal health statement VALID FROM 31 December 2013 YOU SHOULD USE THIS FORM IF YOU ARE: An Employer-sponsored member and: for Death and Total and Permanent Disablement
More informationMedical examination form
Underwriting Medical examination form Questions 1, 2 and 3 of Section 1 are to be completed by the life insured prior to the examination. The medical examiner will discuss the answers with you and add
More informationApplication for Insurance
Application for Insurance About the Application This application needs to be completed by the person to be insured. Please complete the application in BLACK ink pen only. Any changes made to this application
More informationApplication forms. Life s better with the right partner
Application forms Life s better with the right partner Short Personal Statement Death and TPD cover up to $1,250,000 and/or Income Protection cover up to $10,000 per month If you: are aged 60 or older;
More informationKEY PERSON INSURANCE (Accident & Sickness) PROPOSAL FORM
KEY PERSON INSURANCE (Accident & Sickness) PROPOSAL FORM E.U. DISCLOSURE CLAUSE (UK) tice to the Proposer/Insured The Parties are free to choose the law applicable to this insurance Contract. Unless specifically
More informationWoolworths NSW Member Income Protection Form
Woolworths NSW Member Income Protection Form Complete this form if you want to apply for or increase your Income Protection insurance cover. Income Protection insurance cover, also known as salary continuance
More informationApplication for Insurance Cover form
Application for Insurance Cover form Please complete the sections below and return to: PO BOX 666, CARLTON SOUTH, VIC 3053 Please complete this form using BLOCK LETTERS and a blue or black pen. Please
More informationLife Insurance Pre-assessment Request
Life Insurance Pre-assessment Request Financial Adviser: Business name: Phone number: Client Surname: First Initial: Age next birthday: Gender: About this document This Life Insurance Pre-assessment Request
More informationPersonal Accident & Illness Application Form
Personal Accident & Illness Application Form Personal Accident & Illness Application Form Important Notice to the Proposer for completion of this proposal form 1. Disclosure Any 'material fact' must be
More informationMORE INFORMATION. GESB member number. Applying for insurance cover in: GESB Super OR West State Super
Insurance application Personal Statement and Member DECLARATION Member Services Centre 13 43 72 Facsimile 1800 300 067 gesb.com.au PO Box J 755, Perth WA 6842 Level 4 Central Park, 152 St Georges Terrace,
More informationLife Insurance Plans Application Forms
You can either complete this form here on screen or print it off and complete it by hand. Either way you will need to print it off, sign it and physically post it to us through Despatch or via Royal Mail.
More informationApplication for Insurance
Incorporates personal health statement Medical & Associated Professions Superannuation Fund Employer Division members To top-up your default insurance cover within 120 days of joining your employer (subject
More informationIncreases and/or Additions
Supplementary Personal Statement for Increases and/or Additions Adviser name: Adviser e-mail: Adviser code: Proposal/Policy No of Birth Are you a permanent Australian resident? Yes No Increase Addition
More informationLife Insurance Plan Application form
Life Insurance Plan Application form Applicant One Mr/Mrs/Ms/Miss Surname Forename(s) Date of Birth Gender M F Height Weight Do you smoke, or have you in the last 12 months? Yes No If yes, how many do
More informationANZ Superannuation Savings Account Life Insurance Application Form
12 March 2014 Customer Services Phone 13 38 63 Fax 02 9234 6668 Email customer@onepath.com.au Website anz.com Note: Please ensure you complete all details on this form. Any missing details will delay your
More informationVoluntary Salary Continuance Insurance Plan - Elite
Voluntary Salary Continuance Insurance Plan - Elite Issued by REI Superannuation Fund Pty Ltd, ABN 68 056 044 770, AFSL Number 240569, RSE Licence L0000314, as Trustee of REI Super ABN 76 641 658 449,
More informationAPPLICATION FOR ADDITIONAL INSURANCE
APPLICATION FOR ADDITIONAL INSURANCE APPLY ONLINE AND OBTAIN A DECISION IN LESS THAN 10 MINUTES mtaasupercom.au/insurance To apply for additional cover, complete the ONLINE APPLICATION on the MTAA Super
More informationAIA International Limited Personal Life & Medical Insurance Program For Members of Hong Kong Institute of Certified Public Accountants Application
AIA International Limited Personal Life & Medical Insurance Program For Members of Hong Kong Institute of Certified Public Accountants Application Form Personal Details of Insured Person Member Accountant
More informationLoan Protection Plan. Product Disclosure Statement. Issued By: Hannover Life Re of Australasia Ltd and QBE Insurance (Australia) Limited
Loan Protection Plan Product Disclosure Statement Issue date: 18 April 2016 Issued By: Hannover Life Re of Australasia Ltd and QBE Insurance (Australia) Limited Distributed by: ALI Group Table of contents
More information% of time working at heights % What is the average height you work at?
Relevant for Income Protection cases only: 18 Do any of the following form an essential part of your work? a manual work YES NO % of time at Manual work % b Driving YES NO % of time Driving % Average weekly
More informationIOOF Application for Insurance Incorporates personal health statement
IOOF Application for Insurance Incorporates personal health statement 1 January 2014 This form should also be used to apply for or change any existing insurance you may have EXCLUDING any retail insurance
More informationLife Insurance Application Form
Life Insurance Application Form INSTRUCTION To be completed by all applicants PERSONAL DETAILS Surname First name Middle name Sex Female Male Marital status (please tick) Single Married Other Current residential
More informationGROUP INSURANCE EVIDENCE OF INSURABILITY FORM. SECTION 1: EMPLOYER INFORMATION (to be completed by authorized Plan Administrator):
GROUP INSURANCE EVIDENCE OF INSURABILITY FORM RBC Life Insurance Company 6880 Financial Drive, Tower 1, Eighth Floor Mississauga, Ontario L5N 7Y5 Please answer all applicable questions; all subsequent
More informationSimply Smarter Life Insurance. Budget Direct Life Insurance and Budget Direct Accidental Death Insurance Product Disclosure Statement
Simply Smarter Life Insurance Budget Direct Life Insurance and Budget Direct Accidental Death Insurance Product Disclosure Statement Budget Direct Life Insurance and Budget Direct Accidental Death Insurance
More informationEasylife Insurance. MBF Life. Product Disclosure Statement. Issue No.1 11 March 2004
Easylife Insurance Product Disclosure Statement Issue No.1 11 March 2004 MBF Life Issued by: MBF Life Limited ABN 12 000 021 581 AFS Licence No. 227682 Contents About this Product Disclosure Statement...1
More informationMortgage Protection Plan/Level Term Plan With/Without Critical Illness Cover
Metropolitan Police Friendly Society Berwick House, 8-10 Knoll Rise, Orpington, Kent, BR6 0EL Despatch: MPFS Orpington - Phone: 01689 891454 - Metphone: 2 Email: enquiries@mpfs.org.uk - Web: www.mpfs.org.uk
More informationUse a separate piece of paper if you need any more space for any of your answers but please sign and date it.
Alteration Form NOTES Please read these notes carefully before completing the application form. Please make sure that you: Use blue or black ink; Use BLOCK CAPITALS throughout; Correct and initial any
More informationDATA CAPTURE FORM LIFE INSURANCE
DATA CAPTURE FORM LIFE INSURANCE APPLICANT 1 APPLICANT 2 Title First Names Surname Date of Birth Marital Status Address Telephone Email In which country were you born? In the last 2 years, have you lived
More informationInsurance Transfer Form Russell SuperSolution Master Trust Private Division
Insurance Transfer Form Russell SuperSolution Master Trust Private Division If you hold insurance cover in another superannuation fund or directly with another life insurer, you can apply to transfer your
More informationPERSONAL ACCIDENT & ILLNESS APPLICATION FORM
Adelaide Office 277 Magill Road Trinity Gardens SA 5068 PO Box 309 Kent Town SA 5071 Phone: (08) 8291 2300 Fax: (08) 8333 0034 DX: 426 PERSONAL ACCIDENT & ILLNESS APPLICATION FORM Client Details Name of
More informationScotiaLife Critical Illness Insurance Application
ScotiaLife Critical Illness Insurance Application Group Policy Number: 50184 PO Box 215, Stn Waterloo, Waterloo, ON N2J 3Z9 Simply complete, sign and return this Application Form. NO NEED TO SEND MONEY
More informationGroup Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance
Group Benefits Evidence of Insurability for Comprehensive Optional Critical Illness Insurance INSTRUCTIONS - Please print all answers If required, retain a photocopy for your files. 1a) Plan contract number(s)
More informationTransferring your insurance cover into Bendigo and Adelaide Bank Staff Super
Staff Superannuation Plan a sub-plan of IOOF Employer Super 1 January 2014 Transferring your insurance cover into Bendigo and Adelaide Bank Staff Super If you hold insurance cover in another superannuation
More informationApplication Form. New application Change my current plan/deductible. Add spouse/partner/dependents Reinstatement
Application Form Important: Please make sure all the information required on this health insurance application has been provided. Best Doctors Insurance Limited reserves the right to contact the if a question
More informationFull Name & Title. Date of birth. Marital status. Address. Smoker/Non-Smoker
Full Name & Title Date of birth Marital status Address First Person Second Person Smoker/Non-Smoker (Have you used any tobacco/nicotine/electronic cigarettes products in the last 12 months?) Doctors Surgery
More informationTransfer of Insurance to SMSF or Investment Platform
Transfer of Insurance to SMSF or Investment Platform Reference Number (Please ensure the correct quote illustration is attached to this Application Form) Life to be insured name Important Information Before
More informationInsure your life for the price of a coffee. Term Life Insurance Product Disclosure Statement and General Policy Terms
Term Life Insurance Product Disclosure Statement and General Policy Terms Insure your life for the price of a coffee. $100,000 of Term Life insurance cover from just $3 a week.* Issued by: St Andrew s
More informationPATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
More informationINTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE
INTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE FOR U.S. Dollar Term Life Insurance for use when there is an international insurable interest involved. USES Employees of Foreign National Firms International
More informationHow To Fill Out A Health Declaration
The English translation has no legal force and is provided to the customer for convenience only. The Dutch health declaration should be filled in. Health declaration for occupational disability insurance
More informationGenerali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form
Generali Worldwide Group Health Insurance Enrolment and Health Insurance Applicant Form Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate. A completed Health Insurance
More informationAdjusting your insurance cover
REI Super - Elite Adjusting your insurance cover You can adjust the insurance cover you have with REI Super Elite to suit your personal circumstances. Please refer to your Product Disclosure Statement
More informationOptional Income Protection Insurance
Optional Income Protection Insurance for Accumulation members What is Income Protection Insurance? Income protection insurance provides you with a regular monthly income of up to 75% of your super salary*
More informationThe insurance company checked above (Company) is responsible for the obligation and payment of benefits under any policy that it may issue.
American International Life Assurance Company of New York* Home Office: 80 Pine Street, New York, NY 10005 The United States Life Insurance Company in the City of New York* Home Office: 830 Third Avenue,
More informationFlexible Savings Plan
1of14 Clerical Medical Flexible Savings Plan Protection benefits explained abcd 2of14 Protection benefits explained The Clerical Medical Flexible Savings Plan includes a number of optional protection benefits
More informationLife & PHI Application Form
Life & PHI Application Form A. Applicant 1) Mr Mrs Miss Other: 2) Family Name: 3) First Name: 4) Date of Birth: 5) Nationality: 6) Place of Birth: 7) Location of Assignment: 7) Occupation (please give
More informationLIFE INSURANCE INDUSTRY GENERIC PERSONAL STATEMENT
LIFE INSURANCE INDUSTRY GENERIC PERSONAL STATEMENT FOR USE AS AN ATTACHMENT TO LIFE RISK INSURANCE APPLICATIONS INSTRUCTIONS REGARDING ACCESS TO THIS FORM AND CURRENCY The soft currency of the form is
More informationVoluntary Benefits Employee Enrollment and Change Form
LifeMap Assurance Company TM P.O. Box 1271, MS E-3A Portland, OR 97207-1271 (503) 721-7161 (800) 794-5390 Voluntary Benefits Employee Enrollment and Change Form For residents of Oregon and Washington,
More informationU.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY #
U.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY # POLICY OWNER HOME PHONE INSURED HEIGHT WEIGHT DATE OF BIRTH SOCIAL SECURITY NO. WORK PHONE PLEASE NOTE ANY CHANGE OF
More informationVoluntary Benefits Employee Enrollment and Change Form
Voluntary Benefits Employee Enrollment and Change Form LifeMap Assurance Company TM For residents of Oregon and Washington, the definition of a Spouse includes your legal husband or wife or your State
More informationU.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY #
U.S. FINANCIAL LIFE INSURANCE COMPANY REQUEST FOR POLICY REINSTATEMENT FOR POLICY # POLICY OWNER HOME PHONE INSURED HEIGHT WEIGHT DATE OF BIRTH SOCIAL SECURITY NO. WORK PHONE PLEASE NOTE ANY CHANGE OF
More informationApplication to increase insurance Form
Application to increase insurance Form Complete this form if you wish to apply for insurance cover or increase your existing cover with QIEC Super. Return your completed form to QIEC Super Administration.
More informationINTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE
INTERNATIONAL AND SPECIAL USE TERM LIFE INSURANCE FOR U.S. Dollar Term Life Insurance for use when there is an international insurable interest involved. USES Employees of Foreign National Firms International
More informationAPPLICATION FOR DISABILITY INSURANCE
PART I APPLICATION FOR DISABILITY INSURANCE to: Stan PETERSEN Patterson INTERNATIONAL - Broker UNDERWRITERS # 17696 23929 Valencia Blvd., Suite 215, Valencia, California 91355 (800) 345-8816 info@internationalhealthins.com
More informationTransferring your insurance cover into JR Super
The JR Superannuation Fund is a division of IOOF Employer Super. IOOF Employer Super is one of many products and services offered by the IOOF group. Transferring your insurance cover into JR Super If you
More informationLife Cover: Application and amendment form
Universities AVC Facility Life Cover: Application and amendment form Please use black ink and write in CAPITAL LETTERS or tick as appropriate. Any corrections must be initialled. Please do not use correction
More informationFamily Life Protection. Product Disclosure Statement
Family Life Protection Product Disclosure Statement This Product Disclosure Statement contains important information about Family Life Protection. Issued by NobleOak Life Limited ABN 85 087 648 708 AFS
More informationIt is very important that you tell us if there is a change to any of the following:
Pensions Health questionnaire Please use black ink and write in CAPITAL LETTERS or tick 4 as appropriate. About this form Please use BLOCK CAPITALS and tick or complete answers as appropriate. Please take
More informationNORTH WALES POLICE FEDERATION GROUP LIFE CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM
NORTH WALES POLICE FEDERATION GROUP LIFE CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM This scheme is open to any Police Staff or Serving Officer who is also a member of the North Wales Police Federation
More informationWorkman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
More informationSun Life and Health Insurance Company (U.S.)
Sun Life and Health Insurance Company (U.S.) One Sun Life Executive Park, Wellesley Hills, MA 02481] [800-247-6875 Evidence of Insurability Cover Page Employer Instructions Complete this cover page and
More informationData Capture Form - Broker Life Choice
Data Capture Form - Broker Life Choice Please tick ( ) one box only. Life Choice - Home Life Choice - You and Family Life Choice - Assets Note: If you wish to apply for two or more policies a separate
More informationTransferring your insurance cover into the Medical & Associated Professions Superannuation Fund
AMA Financial Services Medical & Associated Professions Transferring your insurance cover into the Medical & Associated Professions If you hold insurance cover in another superannuation fund or directly
More informationLANCASHIRE POLICE FEDERATION CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM
LANCASHIRE POLICE FEDERATION CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM This scheme is open to any Police Staff or Serving Officer who is also a member of the Lancashire Police Group Insurance
More informationInsurance Protection for Contract Courier Drivers
Masefield Holdings Pty Ltd ACN 009 128 394 ABN 70 970 795 411 As Trustee for the GRAHAM KNIGHT UNIT TRUST Trading as Graham S Knight & Associates Insurance Brokers PO Box 160 BELMONT WA 6984 Telephone:
More informationInsurance request VicSuper FutureSaver
GPO Box 89 Melbourne Vic 3001 VicSuper Member Centre 1300 366 216 vicsuper.com.au Insurance request VicSuper FutureSaver * Indicates that providing this information is mandatory. Not doing so may delay
More informationPersonal Accident and Illness Proposal Form
Important Notice Personal Accident and Illness Proposal Form All questions must be answered in full where appropriate. Please complete all details in BLOCK CAPITALS and initial any alterations. It is essential
More informationApplication for Optional Life Insurance
Application for Optional Life Insurance Contract number 50146 Please PRINT clearly. 1 General information Graduate Students Association of the University of Alberta In this application you and your refer
More informationSPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink)
SPORTS INSURANCE PROPOSAL FORM (All questions must be answered in ink) Hanleigh Management Inc. Hanleigh Management, Inc., Hanleigh General Agency, Inc. 50 Tice Blvd., Suite 122, Woodcliff Lake, New Jersey
More informationPersonal Accident & Sickness (Key Man) Proposal Form
Personal Accident & Sickness (Key Man) Proposal Form Important Notice All questions must be answered to enable a quotation to be given. Completing and signing the proposal does not bind the proposers or
More informationDiabetes Questionnaire
Diabetes Questionnaire UFS Duty of Disclosure (Insurance Contracts Act 1984) Your Duty of Disclosure Before you enter into a contract of life insurance with an insurer, you have a duty, under the Insurance
More informationLife and Total and Permanent Disability Superannuation Insurance
AMP Elevate Life and Total and Permanent Disability Superannuation Insurance Contents A Important information 2 A.1 Keep this document safe 2 A.2 This plan is not a savings plan 2 A.3 Cooling-off period
More informationApplication for increase and alteration
Application for increase and alteration MLC Life Cover Super MLC Personal Protection Portfolio Policy number(s) Increase Alteration If you re only changing your occupation group, please use the Change
More informationLoan Protection Plan
Issued by Short form product disclosure statement NO APPLICATION FORM Please note, this document does not contain an application form. Loan Protection Plan Convenient risk protection for your loan Issue
More informationProtecting you and your family. Insurance guide. www.csf.com.au. Effective 1 April 2014
Protecting you and your family Insurance guide Effective 1 April 2014 www.csf.com.au Issued by CSF Pty Limited ABN 30 006 169 286, AFSL 246664, Trustee of the Catholic Superannuation Fund ABN 50 237 896
More informationLife Cover: Application and Amendment Form. Teachers AVC Facility
Life Cover: Application and Amendment Form Teachers AVC Facility Name of scheme Scheme reference number (Please refer to your Teacher's AVC benefit statement if you have one) Part 1 Personal details I
More informationLife Assurance. For Broker Use Only. Application Form. Please complete in all cases. Email address for communication: Contact details
ssurance Application Form For Broker Use Only Please complete in all cases Email address for communication: Contact details esp policy number if applicable Straight to policy (To avail of Free Cover if
More informationFriends Life Protect+ Data capture for online personal cover, business cover and tele-interviewing
Friends Life Protect+ Data capture for online personal cover, business cover and tele-interviewing FLIP/5441/Mar15 This form is not an application form, but is intended to help advisers gather information
More informationCOLONIAL INSURANCE APPLICATION
LIFE INSURANCE APPLICATION COLONIAL INSURANCE APPLICATION A Member of the BSP Group Please Please check complete all details, relevant then areas complete of the the form, relevant check areas all of details
More informationPATIENT INFORMATION SHEET. Last Name: First Name: MI: Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #:
PATIENT INFORMATION SHEET PATIENT Last Name: First Name: MI: Gender: M F Date of Birth: / / SS# Home Address: Apt# City: State: Zip Code: Home Phone #: Cell Phone #: Employer Name: Work Phone #: Email
More informationPERSONAL ACCIDENT AND ILLNESS/INCOME PROTECTION CLAIM FORM
PERSONAL ACCIDENT AND ILLNESS/INCOME PROTECTION CLAIM FORM Effective 01.10.2008 www.compassuw.com How to complete this claim form Please read carefully Please make sure all sections are fully completed
More informationTOURO COLLEGE. To: Full-Time Staff. From: Rosie Kahan./!J! Director of Hluman Resources SUPPLEMENTAL LIFE INSURANCE. Date: August 31, 2007
TOURO COLLEGE Office of Human Resources Ne~v 27-33 West 23rd Street York, NY }OO]0-4202 Phone (212) 463-0400 Fax (212) 627-8975 MEMORANDUM~ To: Full-Time Staff From: Rosie Kahan./!J! Director of Hluman
More informationREHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over) Rehab Resources, Inc. is a certified agency that provides outpatient therapy services. Occupational, Physical,
More informationINDIVIDUAL LIFE INSURANCE APPLICATION PART II - MEDICAL EXAMINATION
INDIVIDUAL LIFE INSURANCE APPLICATION PART II - MEDICAL EXAMINATION ReliaStar Life Insurance Company, 20 Washington Avenue South, Minneapolis, MN 55401 Security Life of Denver Insurance Company, 1290 Broadway,
More informationPersonal Declaration of Health
Personal Declaration of Health 1 Important tes: Please answer all of the questions on this form honestly and in full. If you miss out or give us misleading information, this may mean that a claim will
More informationEvidence/Proof of Insurability for Disability Insurance
Evidence/Proof of Insurability for Disability Insurance This form is for residents of Florida. Instructions for Employer/Benefit Administrator: 1. Please complete Part 1 of the form as applicable to the
More informationINSURANCE World of Protection Upgrade Announcement
INSURANCE World of Protection Upgrade Announcement Leading Life Leading Life in OnePath MasterFund Recovery Cash Stand Alone Recovery Income Safe Plus Income Cover Income Safe Business Expenses Plan July
More information