Complete this form if you want to apply for or increase your Income Protection insurance cover. Suburb/City/Town State/Territory Postcode

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1 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 continuance insurance, is separate from our Death and Total & Permanent Disablement (TPD) or Death Only cover. This type of insurance is designed to provide an income where you are unable to work as a result of an injury or illness and are receiving reduced or no income. The benefit you receive is paid for a period of up to two years. You have the flexibility to choose from a 0, 60 or 90 day benefit waiting period. Income Protection insurance cover is available with or without our Death and Total & Permanent Disablement (TPD) or Death Only cover. The maximum benefit you can receive is 85% of your pre-injury or illness salary. This is made up of up to 75% paid to you as income and any amount above this up to 10% paid as a super contribution into your LUCRF account. A maximum sum insured of up to $0,000 per month applies. Note: Your Income Protection payment may be reduced if you receive any employment income, workers compensation, social security or other statutory or Government payments at the time you make a claim. Income Protection cover is not available to casual employees or employees working less than 15 hours per week. Please complete all relevant sections using CAPITAL LETTERS and a BLACK or BLUE pen. Step 1 Your details LUCRF Super membership number Date of birth (dd/mm/yyyy) / / Please cross [ ] the appropriate box: Mr Mrs Miss Ms Other (please specify) Surname First name(s) Residential/Street address (compulsory) Unit/Street number Street name Suburb/City/Town State/Territory Postcode Postal address if different to residential Unit/Street/PO Box number Street name Suburb/City/Town State/Territory Postcode Please send all correspondence to (please cross [ ]): Residential address Postal address Contact details Mobile Work Home address Please read our Personal Information Collection Statement at lucrf.com.au/privacy Issued by 1 July 2014 L.U.C.R.F Pty Ltd ABN AFSL as Trustee for Labour Union Co-operative Retirement Fund ABN (LUCRF Super). LUCRF0526_0714 Member Income Protection Form Page 1 of 5

2 Income Protection cover Insurance tables The cost of Income Protection insurance with LUCRF Super depends on your age, gender, work category and the waiting period you select. The example below is to help you determine how to calculate the level and cost of cover that may suit you. Example John 25 years old at next birthday Heavy Machine Operator (Heavy Blue Collar) Gross weekly salary of $ day waiting period. Wants cover of $765 (85% of $900) Cost of cover $0.6 per $100 weekly benefit Maximum cover limit John can apply up to 85% of his salary ($765 per week) How to work out cover $900 per week salary x 85% (of gross salary) = $765 per week So, $765 per week / $100 weekly benefit = 8 units (rounded to the nearest $100) 8 units x $0.6 = $2.88 per week John chooses $800 per week of income protection cover Cost per week $2.88 (deducted from John s super account) Refer to the tables below to determine the cost of your Income Protection insurance cover. Weekly Premium per $100 weekly benefit 0 day waiting period day waiting period day waiting period Member Income Protection Form Page 2 of 5

3 Step 2 Your work category To ensure you receive the correct insurance cover we need to identify the work category that best represents the type of work you do. Please cross [ ]: What is the name of your current employer? What is your main occupation? If yes, please specify your occupation(s) Are you engaged in any other occupations? YES NO 1. Do you spend at least 80% of your total working time in an office or similar environment performing administrative, clerical or sedentary type duties? (This includes the total amount of time spent in all occupations as advised above) YES NO If yes, proceed to questions 2 and. If no, proceed to questions 4 and 5. Only complete questions 2 & if you answered yes to question Do you have a university degree qualification relevant to the field of your main occupation or, are you an executive or senior managerial white-collar worker and not self-employed or are you a member of a professional institute? YES NO. Is your current annual salary package (including superannuation guarantee contribution) in excess of $150,000? YES NO Only complete questions 4 & 5 if you answered no to question Do you have a recognised trade qualification relating to you occupation or, does your occupation require you to perform light manual work or, are you a supervisor of blue collar workers and your duties include up to 10% of light manual work? (e.g. an electrician, mechanic, printer, signwriter, greengrocer, carpenter, storeman, poultry processing employee, plumber etc? YES NO 5. Are you a skilled or semi-skilled worker whose duties include heavy manual work or are you required to operate heavy machinery (e.g. qualified wall/floor tiler, glazier, bulldozer driver, forklift driver)? YES NO If you answer yes to questions 1, 2 and you will be classified as Professional. If you answer yes to question 1 and no to either question 2 or, you will be classified as White Collar. If you answer no to questions 1 and 5 and yes to question 4, you will be classified as Light Blue. If you answer no to questions 1 and 4 and yes to question 5, you will be classified as Heavy Blue. If you answer no to questions 1, 4 and 5, income protection cover will be declined. Step Select the amount of cover you want to apply for Please complete this section to apply for Income Protection insurance cover. I am currently working in excess of 15 hours per week (cross [ ] one box only): Yes No I am a casual employee (cross [ ] one box only): Yes No Gender (cross [ ] one box only): Female Male Note: Income Protection cover is not available to casual employees, or employees working less than 15 hours per week. Please select your waiting period (cross [ ] one box only): 0 days 60 days 90 days Member Income Protection Form Page of 5

4 Step a Within 90 days of your welcome letter Apply for up to $700 per week cover by answering one simple question and complete steps 1, 2,, a and 6. If you do not currently have Income Protection insurance through LUCRF Super you can obtain: Total Income Protection insurance up to $700 per week ($6,400 per year) I would like to be apply for a total benefit of $ weekly benefit of Income Protection cover (benefit must be a multiple of $100) As at the date of signing this application, I confirm that: I am off work due to injury or illness or restricted from performing any of the usual duties of my occupation due to injury or illness on a full time basis of at least 0 hours per week (even if not currently working on a full-time basis for non-medical reasons) YES NO (Note: You must answer NO to the question to be eligible for the cover. If you cannot answer NO you can still apply for cover by completing the OnePath Personal Statement). Step b After 90 days of your Welcome letter or for cover above $700 per week After 90 days of your welcome letter or for cover above the AAL Apply for cover up to the maximum benefit amount of up to $0,000 per month For cover up to $7,000 per month complete steps 1, 2,, b, 4 and 6 For cover above $7,000 per month complete steps 1, 2, b, 6 and a OnePath Personal Statement If you do not currently have Income Protection Insurance through LUCRF Super you can obtain: I would like to be apply for a total benefit of $ weekly benefit of Income Protection cover (benefit must be a multiple of $100) If you are employer sponsored and applying for Income Protection Insurance cover in excess of $7,000 per month, you will need to complete a OnePath Personal Statement. To obtain a copy of the OnePath Personal Statement, please call LUCRF Super on or download a copy from lucrf.com.au Step 4 Health questions (employer sponsored members only) You need to complete all the health questions below to apply for Income Protection insurance cover with LUCRF Super. Please cross [ ] boxes for Yes or No. To the best of your knowledge: 1. Other than to combat a cold or flu, a. are you, at the date of this application, off work due to injury or illness or restricted from performing any of the usual duties of your occupation due to injury or illness? YES NO b. are you currently receiving any form of medical treatment or taking any form of medication? YES NO c. have you taken more than a total of seven consecutive days off work over the past 12 months due to illness or injury? YES NO 2. Have you ever received medical advice, consulted a doctor, undergone medical treatment, investigations or operations for, or suffered from any of the following: a. cancer, tumour or growth including breast lumps or skin lesions/moles (even if you have not seen a doctor), high blood pressure, high cholesterol, heart complaint, murmur, palpitations or chest pain, stroke, thyroid or glandular disorder or diabetes? YES NO b. back or neck pain/disorder, musculo-skeletal symptoms or any joint disorder, gout, arthritis, repetitive strain syndrome, paralysis of any kind, chronic fatigue syndrome, epilepsy or neurological disorder, or mental/nervous disorder including stress, anxiety or depression? YES NO c. kidney, bowel, bladder, gall bladder, liver disease or disorder, lung or other organ disorder, hepatitis, hernia, blood disorder, sleep-apnoea, asthma or persistent cough or any lung complaint, or any abnormality of hearing, speech or eyesight (excluding glasses or contact lenses)? YES NO. Have you ever tested positive for HIV (Human Immunodeficiency Virus), which causes AIDS (Acquired Immune Deficiency Syndrome), or are you suffering from AIDS or any AIDS related conditions? YES NO 4. a. What is your current height? (cm s) b. What is your current weight? (kg s) If you have crossed YES to any of the boxes for the health questions above, or are applying for cover in excess of $7,000 per month, you will need to complete a OnePath Personal Statement. To obtain a OnePath Personal Statement, please call LUCRF Super on or download a copy from lucrf.com.au If you have crossed NO to all of the above health questions and you are applying for less than $7,000 per month cover, you will be provided with the cover you have chosen when you receive your letter of confirmation. Member Income Protection Form Page 4 of 5

5 Step 5 OnePath Personal Statement (Personal Plan members only) In order for you to apply for, or change your insurance cover as a LUCRF Super Personal Plan member, you will also need to complete a OnePath Personal Statement. To obtain a copy, please call LUCRF Super on or download a copy from lucrf.com.au Step 6 Sign and date this form Duty of disclosure You have a duty, under the Insurance Contracts Act 1984 to disclose to the Insurer every matter that you know, or could reasonably be expected to know, that is relevant to the Insurer s decision whether to accept the risk of the insurance, and if so, on what terms. Your duty, however, does not require disclosure of a matter: That diminishes the risk to be undertaken by the Insurer That is common knowledge That your Insurer knows or, in the ordinary course of his/her business, ought to know As to which compliance with your duty of disclosure 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 void the contract within years of having entered into it. If your non-disclosure is fraudulent, the Insurer may void the contract at any time. An Insurer who is entitled to void a contract of life insurance may, within years of entering into it, elect not to void it but to reduce the sum 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. I declare that: I understand my duty of disclosure and the effect of non-disclosure under the Insurance Contracts Act I have answered all questions in this application truthfully and correctly (to the best of my knowledge), and have disclosed everything I know that could affect OnePath Life s decision to accept my application. I understand that I must advise OnePath Life of any changes in my health from now until I am notified in writing that my application has been accepted. I understand that insurance cover through LUCRF Super will be provided to me on the terms contained in LUCRF s insurance policy as changed from time to time. I have read and understood the Super Member Guide (Product Disclosure Statement) and the associated reference material as currently available at lucrf.com.au/forms-and-publications I consent to the collection, use and disclosure of my personal information in accordance with the OnePath Life Privacy Statement, available at onepath.com.au/privacy-policy or by calling , and the LUCRF Super Personal Information Collection Statement and Privacy Policy available at lucrf.com.au/privacy or by calling I understand that if my application is accepted I will be notified in writing and my insurance cover will change in accordance with the direction I have made in this form. The change will be effective from the date LUCRF s insurer accepts this application and provided my member account has adequate funds to meet the premium payable. Member signature 7 Date (dd/mm/yyyy) / / Checklist Before you send the form to us, make sure you have: Answered the health questions honestly Indicated the amount of cover you wish to apply for Completed and attached a OnePath Personal Statement (if required) Signed and dated this form Send this form to: LUCRF Super PO Box 211 North Melbourne VIC 051 F E If you need any help completing this form, please call us on or Member Income Protection Form Page 5 of 5

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