Transfer of Insurance to SMSF or Investment Platform

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Transfer of Insurance to SMSF or Investment Platform"

Transcription

1 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 you complete this application form, be aware that TAL or a financial adviser must have provided you with a Product Disclosure ment (PDS) for Accelerated Protection for Investment Platforms dated 12 December The PDS contains important information in relation to Accelerated Protection. Please complete in black ink, using BLOCK letters. Use X in boxes. Use this Transfer of Insurance to SMSF or Investment Platform form to transfer cover to Accelerated Protection where the new policy owner is a Self-Managed Superannuation Fund or a Platform Superannuation Fund and the existing policy being replaced: was underwritten within the last five years; is a group insurance policy or a retail insurance policy funded via an investment platform, masterfund, wrap account or similar; and meets the eligibility criteria outlined in the table below. Term TPD Critical Illness Maximum Entry Age 60nb 60nb 60nb Maximum Sum Insured $3,000,000 $2,000,000 $1,500,000 Maximum sub-standard terms considered* 100% loading To age 55nb: 100% loading Age 56 to 60nb: standard rates only To age 55nb: 100% loading Age 56 to 60nb: standard rates only * For medical sub-standard terms, in addition to the medical loading, we will consider additional loadings/exclusions for non-medical risks. A medical exclusion equates to +50% loading. In addition to this application form, we also require evidence of the existing cover to be replaced as follows: copy of the Policy Schedule ; and copy of the letter of acceptance for the existing cover or any other evidence that illustrates the cover was underwritten; and copy of the latest renewal notice showing that the cover is in force and the current benefits; or the Certificate of Currency from the current insurer Duty Of Disclosure For the purposes of this Duty of Disclosure section, You includes both the Policy Owner and the Life Insured. Before you enter into or become insured under a contract of insurance with TAL Life Limited (ABN ) (TAL) you have a duty under the Insurance Contracts Act 1984 to inform TAL of every matter that you know, or could reasonably be expected to know, is relevant to TAL s decision whether to accept the risk of insurance and issue a policy, and if so, on what terms. You have the same duty to disclose those matters to TAL before you apply to extend, vary or reinstate a policy. Your duty however does not require disclosure of a matter that reduces TAL s risk, is common knowledge, that TAL knows or ought to know in the ordinary course of business, or that TAL tells you it does not need to know. Your duty of disclosure applies even after this application is completed and until TAL advises acceptance of your application and issues a Policy Schedule. If you fail to comply with your duty of disclosure or make a misrepresentation and TAL would not have entered into all or part of the policy on the same terms had TAL known about those matters, TAL may avoid all or part of the policy within three years of entering into it. If your non-disclosure or misrepresentation is fraudulent and TAL would not have entered into the policy on the same terms had it known about those matters, TAL may avoid all or part of the policy at any time. Alternatively, instead of avoiding the policy TAL may decide: (a) to reduce the benefits for all or part of the policy in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to us, although any reduction to benefits payable in respect of the death of a Life Insured can only occur within three years of the commencement date; or (b) for any benefits provided under the policy other than benefits payable in respect of the death of a Life Insured, to vary the policy in such a way as to place you in the position you would have been in if you had disclosed all relevant matters to us. TAL Life Limited ABN AFSL TALR0992/1114 Transfer of Insurance to SMSF or Investment Platform page 1 of 9

2 Existing Insurance Details Is the existing policy a group or retail policy? Group Retail Was the existing policy underwritten in the last five years? Yes No Existing insurer Existing policy number If a retail policy, what was the premium funding source? Existing fund number (if applicable) Was the existing policy modified or offered on non-standard terms including a loading or exclusion? Yes No 1. Personal Details Title First name Middle name Last name Previous surname Marital status Single Married/de facto Divorced/widowed Date of birth DD / MM / YYYY Gender Male Female Height cm or Feet Inches Weight kg or Stone Pounds Have you smoked tobacco or any other substance in the last 12 months? Yes No If yes, please answer the following questions: Smoked cigarettes? Yes No If yes, what daily quantity is consumed? Smoked cigars or pipe? Yes No Smoked another substance? Yes No What is the purpose of the cover being applied for? Key person Partnership/Share Purchase Loan Cover Personal Combination 2. Contact Details Residential address (Do not enter a PO Box in this field) Is this your mailing address? Yes No Transfer of Insurance to SMSF or Investment Platform page 2 of 9

3 2. Contact Details Continued If no, please complete below. Mailing address Telephone and Preferred contact number 1 Home Business Mobile Preferred time 1 (AEST): 8am-7.30pm 8am-11am 11am-2pm 2pm-5pm 5pm-7.30pm Preferred contact number 2 Home Business Mobile Preferred time 2 (AEST): 8am-7.30pm 8am-11am 11am-2pm 2pm-5pm 5pm-7.30pm 3. Doctor/Clinic Details Do you have a GP or medical practice that you usually attend? Yes No If yes, please complete below: Name Contact number Contact type: Business Mobile How long ago was your last consultation with this GP or medical practice? Less than 6 months 6 to 12 months 1 to 2 years 2 to 5 years 5 years or more How long have you been attending this GP or medical practice? Less than 6 months 6 to 12 months 1 to 2 years 2 to 5 years 5 years or more If less than 2 years, or you don t currently have a GP or medical practice that you usually attend, please advise the name and contact details of your previous GP or medical practice attended: Name Contact number Contact type: Business Mobile Transfer of Insurance to SMSF or Investment Platform page 3 of 9

4 4. Health & Lifestyle Details 1. In the last five years have you had any symptoms of illness and/or injury, or any condition (other than cold/flu/contraception) for which you sought medical advice and/or treatment? Yes No 2. In the last five years have you had any medication prescribed (other than contraceptives and/or antibiotics)? Yes No 3. In the last five years have you had any medical test(s), investigations or procedures (e.g. ECG, genetic test, colonoscopy, endoscopy, gastroscopy or ultrasound)? Yes No 4. Apart from any condition already disclosed, do you plan to seek medical advice, investigation or treatment for any other current health condition? Yes No 5. Have you ever injected, smoked or otherwise taken recreational or non-prescription drugs, taken any drug other than as medically directed or received advice and/or counselling for excess alcohol consumption from any health professional? Yes No 6. (i) In the last 5 years have you engaged in unprotected anal sexual intercourse, except in a relationship between you and one other person only, and neither of you has had sexual intercourse with anyone else in the last 5 years? Yes No (ii) In the last 5 years have you engaged in sexual intercourse with, or as, a sex worker? Yes No (iii) In the last 5 years have you engaged in sexual intercourse with someone you know, or suspect to be, HIV positive? Yes No 7. Do you currently participate in, or you do have any intention of participating in, any sports or hazardous activities (eg aviation, football, scuba diving, dirt bike riding, motor racing, rock climbing)? Yes No 8. Are you an Australian citizen or do you have an Australian Permanent Resident s visa? Yes No 9. In the next 12 months do you have any plans to travel or live overseas or are you required to travel on a regular basis for business? Yes No Transfer of Insurance to SMSF or Investment Platform page 4 of 9

5 5. Family History 1. Has any of your immediate family (mother, father, brother or sister) suffered from any of the following? Yes No Bowel or breast cancer; Heart disease or stroke; Cardiomyopathy; Type 1 or type 2 diabetes; A neurological condition such as Alzheimer s disease or Multiple Sclerosis; or Any hereditary condition? If yes, please advise relevant condition, number of relatives affected and age(s) at diagnosis: 6. Occupation Details To be completed for TPD application 1. Occupation 2. Employer s name 3. Average hours worked per week hours 4. Outline the duties of your main occupation: Duty % of time Administrative/clerical % Light manual % Supervisor of manual work % Manual work % 5. Are you self employed? (This means you are a business owner, sole trader, an employee of your own company or trust, or are in a partnership.) Yes No 6. Has your occupation or employment status changed (eg from employed to self employed) in the last 5 years? Yes No 7. Income Details Annual salary/remuneration package (gross)* $ * If self employed, this means your share of net business income (Gross business income or Turnover less business expenses) plus any items such as salary and superannuation not already included that are paid to you as a direct result of your personal exertion. If employed, this means your current wages or salary, award superannuation contributions, bonuses, commission, fees, fringe benefits and regular overtime. Transfer of Insurance to SMSF or Investment Platform page 5 of 9

6 8. Other Insurance Details To be completed for Life, TPD and Critical Illness insurance applications 1. Apart from this application, do you have or are you applying for any other Life, TPD or Critical Illness insurance (please include cover held under superannuation)? Yes No A. Is this other insurance being completely replaced by this application? Yes No If no, what will be the total amount of cover in force on your life (including this application)? Note: please include any TPD benefits under Critical Illness type contracts. Financial evidence may be required if total combined cover exceeds our financial underwriting limits. Life $ TPD $ CI $ 9. Policy Owner Policy owner Owner type Platform superannuation fund SMSF Trustee name ABN/ACN Contact number Contact type: Home Business Mobile 10. Preferred Risk Commencement Date (Optional) Please indicate a Preferred Risk Commencement Date if you are replacing cover DD / MM / YYYY that is held elsewhere. Note: You may select a future date between 1 and 60 days from the current date. If TAL is not able to issue the policy by the nominated date, a revised commencement date may apply. If this happens, we will contact your adviser to confirm the revised commencement date. Your Duty of Disclosure applies even after this application is completed and until TAL advises acceptance of insurance and issues a Policy Schedule. 11. Method of Payment Method Cheque Direct Debit Credit Card Platform Frequency Monthly Quarterly Half-yearly Yearly 12. Direct Debit Payment Authority by Credit Card I authorise the debit of my premiums from my: Visa MasterCard Account name Card number Expiry date MM / YYYY cardholder* Date DD / MM / YYYY * Signature(s) only required when the payer is not the Life Insured or Policy Owner. Transfer of Insurance to SMSF or Investment Platform page 6 of 9

7 13. Direct Debit Authority I request and authorise TAL Life Limited (Direct Debit System User Identification Number ) to directly debit my premiums, from my account detailed below, using the Bulk Electronic Clearing System (BECS). I confirm that I have read the Direct Debit Request Service Agreement in the Product Disclosure ment (PDS) and that I have the authority to make these payments. Account name Name of bank BSB number Account number account holder 1* Date DD / MM / YYYY account holder 2* Date DD / MM / YYYY * Signature(s) only required when the payer is not the Life Insured or Policy Owner. 14. Direct Debit from a Platform Account Important Note: Direct Debit from a superannuation or investment platform account is only available where TAL has an agreement with the platform provider. Platform name Account/member number Account name 15. Self-Managed Superannuation Fund Service Details Please provide details where TAL has an agreement with your SMSF Service provider. SMSF Service Provider: Account Name: Account Number (fund ID): Transfer of Insurance to SMSF or Investment Platform page 7 of 9

8 16. Policy Declaration I/we declare that I/we have read the following statements, and I/we agree and acknowledge that: I/we have received a copy of the Accelerated Protection, or Accelerated Protection for Investment Platforms, Product Disclosure ment (PDS), dated 12 December 2014; I/we have read and understand the Duty of Disclosure as set out in the PDS and understand the Duty of Disclosure also applies to Interim cover and that the Duty of Disclosure continues to apply until TAL accepts this application and issues a Policy Schedule; I/we have provided TAL with true, accurate and complete answers in my/our application (including Application Form, quotes and all other forms, questionnaires and information provided to TAL), whether answered by me/us or my adviser, to the best of my/our knowledge; Where my/our application has been submitted electronically to TAL, I/we will review; a printout of the application submitted and will notify my/our adviser of any answers which are incorrect, incomplete or inaccurate; or a summary received by (if I/we have provided TAL with an address for the purpose of receiving a summary of the application by ) and will notify TAL of any answers which are incorrect, incomplete or inaccurate within five business days; I/we will cooperate with TAL if modifications to the Policy conditions are required because of any changes to the answers TAL are notified of; I/we understand that by signing this form, I/we consent to TAL s collection, use and disclosure of my/our personal information in accordance with the section in the PDS headed Your Privacy ; I/we understand that my/our financial adviser is my/our agent and not the agent of TAL; I/we understand that TAL may accept information from my/our financial adviser, or their representative, and that TAL will rely on any such information in deciding whether or not to accept my/our application and in relation to all matters of administration; In relation to any tax returns submitted in support of this application I/we confirm that these are the tax returns submitted to the Australian Taxation Office and no subsequent adjustments have been made or are expected; In the event that TAL determines to not accept my/our application on standard terms; I/we authorise TAL to inform my/our financial adviser, or their representative, of the reasons for that decision. I/we understand that TAL will not provide copies of medical or other reports to my financial adviser, or their business, without first obtaining my/our consent; and I/we authorise my/our financial adviser, or their representative, to communicate to TAL my/our acceptance of any alternative terms on my/our behalf; and I/we have authorised TAL to debit my/our premiums if credit card or bank account details are provided with my application. life to be insured SIGN HERE Date DD / MM / YYYY policy owner 1 If different to the Life Insured SIGN HERE Date DD / MM / YYYY policy owner 2 If different to the Life Insured SIGN HERE Date DD / MM / YYYY Transfer of Insurance to SMSF or Investment Platform page 8 of 9

9 17. Medical Evidence Authority Reference number Date of birth DD / MM / YYYY Name of life to be insured Dear Doctor I have applied to TAL Life Limited (TAL) for insurance and a medical report from your practice is required. Until this report is received by TAL my application for insurance cannot proceed. I have agreed that any Medical Practitioner or any other person who has been or may be consulted by me at any time in the future whether named by me or not shall be and is hereby authorised and directed by me to divulge to TAL, any legal tribunal or any third party engaged by TAL all medical or surgical information acquired with regard to myself. A photocopy or facsimile of this authority shall be considered as valid as the original. I would be grateful if you could attend to this matter as soon as possible. life to be insured Date DD / MM / YYYY 18. Authorised Representative Details Principal Authorised Representative TAL adviser number Authorised Rep name Dealer group Commission split (whole numbers) New business % Servicing % Contact number Contact type: Business Mobile Shared Authorised Representative TAL adviser number Authorised Rep name Dealer group Commission split (whole numbers) New business % Servicing % Note: If splitting commission, new business and servicing commission must each total 100%. Please return the completed form to: TAL Life Limited, GPO Box 5380 Sydney NSW 2001 T F E Transfer of Insurance to SMSF or Investment Platform page 9 of 9

Smart Term Insurance

Smart Term Insurance Smart Term Insurance Combined Product Disclosure Statement and Financial Services Guide Product Disclosure Statement About Smart Term Insurance HCF Smart Term Insurance is a term life insurance product

More information

Transferring your insurance cover into Bendigo and Adelaide Bank Staff Super

Transferring 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 information

ANZ Superannuation Savings Account Life Insurance Application Form

ANZ 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 information

Transferring your insurance cover into JR Super

Transferring 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 information

Transferring your insurance cover into the Medical & Associated Professions Superannuation Fund

Transferring 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 information

Easylife Insurance. MBF Life. Product Disclosure Statement. Issue No.1 11 March 2004

Easylife 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 information

APPLICATION FOR BUPA INCOME PROTECTION

APPLICATION 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 information

Accident/Illness Claim

Accident/Illness Claim QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.

More information

Insurance Personal Questionnaire

Insurance Personal Questionnaire Insurance Personal Questionnaire Name of Client 1: Name of Client 2: This section is completed by your Adviser Adviser Name: Adviser Code: Interview Date: FSG Version Number Provided: Adviser Profile Number

More information

AMP Firstcare Term Life Insurance

AMP Firstcare Term Life Insurance AMP Firstcare Term Life Insurance Customer Information Brochure A simple and convenient way to protect yourself and your family s future Issue 7d Issue 1 February 2002. Expires 31 December 2002. You should

More information

Life Insurance Pre-assessment Request

Life 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 information

Macquarie Term Life Insurance. Product Disclosure Statement

Macquarie Term Life Insurance. Product Disclosure Statement Macquarie Term Life Insurance Product Disclosure Statement Issued by Macquarie Life Limited ABN 56 003 963 773 January 2010 Contents At a glance 01 At a glance 03 Terms and conditions 04 Your Policy 07

More information

Use a separate piece of paper if you need any more space for any of your answers but please sign and date it.

Use 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 information

Application forms. Life s better with the right partner

Application 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 information

Insurance Transfer Form Russell SuperSolution Master Trust Private Division

Insurance 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 information

FirstChoice Employer Super Transfer of Insurance Cover Form

FirstChoice Employer Super Transfer of Insurance Cover Form FirstChoice Employer Super Transfer of Insurance Cover Form B3BQFM 18 May 2015 This form is to be completed for applications to transfer insurance from an external superannuation fund and transfers from

More information

Application for increase and alteration

Application 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 information

LIFE INSURANCE. Product Disclosure Statement

LIFE INSURANCE. Product Disclosure Statement LIFE INSURANCE Product Disclosure Statement This product and Product Disclosure Statement are issued by Suncorp Life & Superannuation Limited ABN 87 073 979 530 AFSL 229880 under the brand, AAMI. Contents

More information

Individual insurance transfer

Individual insurance transfer AON MASTER TRUST Individual insurance transfer Use this form if you are a current member or joining the Aon Master Trust as a new member and you wish to transfer your current insurance cover with another

More information

Loan Protection Plan. Product Disclosure Statement. Issued By: Hannover Life Re of Australasia Ltd and QBE Insurance (Australia) Limited

Loan 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

Diabetes Questionnaire

Diabetes 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 information

Application for Insurance

Application 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 information

Application for increases without further medical evidence

Application for increases without further medical evidence MLC Insurance MLC Insurance (Super) Application for increases without further medical evidence Policy number(s) Name of Life Insured This form allows the Income Protection, Life Cover, Total and Permanent

More information

Family Life Protection. Product Disclosure Statement

Family 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 information

Insure your life for the price of a coffee. Term Life Insurance Product Disclosure Statement and General Policy Terms

Insure 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 information

Heart Disease Questionnaire

Heart Disease Questionnaire Heart Disease 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

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Underwriting Australia Sports Underwriting Australia Claims Department PO E: liabilityclaims@sportsunderwriting.com.au Box 2717, Taren Point. NSW, 2229 Tel: Ph: 1300 363 363 413 413 Fax: +61 2 9524

More information

Accidental Death Insurance at ClearView. Product Disclosure Statement & Policy Wording

Accidental Death Insurance at ClearView. Product Disclosure Statement & Policy Wording Accidental Death Insurance at ClearView Product Disclosure Statement & Policy Wording 1 October 2011 About this document This document contains the Product Disclosure Statement (PDS) and policy wording

More information

Accident/Illness Claim

Accident/Illness Claim QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.

More information

BT Protection Plans. Product Disclosure Statement and Policy Document (PDS)

BT Protection Plans. Product Disclosure Statement and Policy Document (PDS) BT Protection Plans Product Disclosure Statement and Policy Document (PDS) Dated 19 May 2014 Who s responsible for BT Protection Plans The Insurer is Westpac Life Insurance Services Limited ABN 31 003

More information

ACCIDENTAL DEATH INSURANCE

ACCIDENTAL DEATH INSURANCE ACCIDENTAL DEATH INSURANCE Product Disclosure Statement This product and Product Disclosure Statement are issued by Suncorp Life & Superannuation Limited ABN 87 073 979 530 AFSL 229880 under the brand,

More information

Contact AMP You can call or fax a Customer Service Officer on Phone 131 267 Fax 1300 301 267

Contact AMP You can call or fax a Customer Service Officer on Phone 131 267 Fax 1300 301 267 getting a home loan? Easy cover for you Loan Cover Product Disclosure Statement Issue 3, 1 January 2012 Loan Cover is issued by AMP Life Limited ABN 84 079 300 379, AFS Licence No. 233671 Loan Cover is

More information

PERSONAL INCOME PROTECTION APPLICATION

PERSONAL INCOME PROTECTION APPLICATION PROTECTION PERSONAL INCOME PROTECTION APPLICATION Adviser s Name: Agency No.: Please tick (3) where appropriate Please ensure that all questions are answered to prevent any delay in the assessment of your

More information

Depression, Anxiety or Stress Related Condition Questionnaire

Depression, Anxiety or Stress Related Condition Questionnaire Depression, Anxiety or Stress Related Condition 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,

More information

Employer Insurance Application

Employer Insurance Application for Property Focused Employer Sponsored Super Before you sign this application form, the Trustee or your financial adviser is obliged to give you the Property Focused Super Product Disclosure Statement

More information

EVIDENCE OF INSURABILITY COVERAGE DETAIL

EVIDENCE OF INSURABILITY COVERAGE DETAIL EVIDENCE OF INSURABILITY COVERAGE DETAIL This application consists of two parts: The Evidence of Insurability Coverage Detail form and Medical & Lifestyle Questionnaire. INSTRUCTIONS Plan Administrator:

More information

Zurich Wealth Protection

Zurich Wealth Protection Issue Date: 21 December 2015 Zurich Wealth Protection Product Disclosure Statement including policy conditions This PDS, prepared on 25 November 2015, is provided in two parts: Part 1 Policy information

More information

Application for Insurance Cover form

Application 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 information

combined financial services guide, product DiSclosure statement and policy Wording insurance

combined financial services guide, product DiSclosure statement and policy Wording insurance combined financial services guide, product DiSclosure statement and policy Wording Accidental death insurance 28th october 2011 This document is a Combined Financial Services Guide, Product Disclosure

More information

Suncorp Life Protect Product Disclosure Statement

Suncorp Life Protect Product Disclosure Statement Suncorp Life Protect Product Disclosure Statement Prepared on: 20 February 2015 Effective date: 30 March 2015 Important Information This is the Product Disclosure Statement (PDS) for Suncorp Life Protect.

More information

Simply 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 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 information

product disclosure statement Issued by Westpac Life Insurance Services Limited ( Westpac Life )

product disclosure statement Issued by Westpac Life Insurance Services Limited ( Westpac Life ) Westpac Future Cover product disclosure statement Issued by Westpac Life Insurance Services Limited ( Westpac Life ) ABN 31 003 149 157 Australian Financial Services Licence No. 233728 Level 20, Westpac

More information

Personal Accident & Sickness Claim Form IMPORTANT NOTES

Personal Accident & Sickness Claim Form IMPORTANT NOTES Personal Accident & Sickness Claim Form IMPORTANT NOTES PRIVACY STATEMENT In this Privacy section we, us or our means Great Lakes Australia and Winsure, unless specified otherwise. CONTACT US We are committed

More information

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

AMP Life Insurance. Product Disclosure Statement and policy document

AMP Life Insurance. Product Disclosure Statement and policy document AMP Life Insurance Product Disclosure Statement and policy document Issue date: 12 March 2014 Contents Summary 1 Product issuer 1 Other companies involved in providing services 1 for the AMP Life Insurance

More information

My plan. Their future. Heading goes. here. Powered by Citi. Powered by Citi. Pure Life. Product Disclosure Statement Issued 025 March?

My plan. Their future. Heading goes. here. Powered by Citi. Powered by Citi. Pure Life. Product Disclosure Statement Issued 025 March? Pure Life My plan. Heading goes Their future. here. Powered by Citi. Powered by Citi. Product Disclosure Statement Issued 025 March? April 2011 Issuer: Distributor: MetLife Insurance Limited Citigroup

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Please return claim form to: Corporate Services Network 2 / 280 George Street Sydney NSW 2000 Ph: +61 2 8256 1770 Fax: +61 2 8256 1775 E-mail: claims@csnet.com.au Employer: Claimants Name: Job Title: Work

More information

Bentham Asset Management Application Form. Customer identification. Contact details. Checklist. Use this application form if you wish to invest in:

Bentham Asset Management Application Form. Customer identification. Contact details. Checklist. Use this application form if you wish to invest in: Bentham Asset Management Application Form Use this application form if you wish to invest in: Bentham Wholesale Global Income Fund Bentham Wholesale Syndicated Loan Fund Bentham Wholesale High Yield Fund

More information

Business Superannuation Financial Needs Analyser

Business Superannuation Financial Needs Analyser Business Superannuation Financial Needs Analyser Employer details Employer Name: Industry Phone: Address: Level 19, 1 Alfred Street Sydney, NSW, 2000 GPO Box 3323 Sydney, NSW, 2001 Telephone: (02) 8272

More information

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

Complete 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 information

Personal Statement/ Member s Statement

Personal 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 information

Full Personal Statement

Full 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 information

Insurance request VicSuper FutureSaver

Insurance 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 information

MemberCare Life Insure Policy

MemberCare Life Insure Policy MemberCare Life Insure Policy Product Disclosure Statement incorporating the Policy Wording Your family s complete protection Introduction & Welcome We understand how important it is to be comfortable

More information

% of time working at heights % What is the average height you work at?

% 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 information

Pay-by-the-month insurance. Application form

Pay-by-the-month insurance. Application form Pay-by-the-month insurance Application form Pay-by-the-month insurance Select your payment method With GIO pay-by-the-month you can smooth out your business cash flow by paying over 12 months, direct through

More information

Product Disclosure Statement

Product Disclosure Statement Product Disclosure Statement 30 September 2013 ClearView LifeSolutions is issued by ClearView Life Assurance Limited: ABN 12 000 021 581, AFS Licence No. 227682. ClearView LifeSolutions Super is issued

More information

Westpac Protection Plans

Westpac Protection Plans Westpac Protection Plans Supplementary Product Disclosure Statement and Policy Addendum (SPDS) Dated 1 July 2014 This SPDS is dated 1 July 2014 and supplements the information contained in the Westpac

More information

Your People, Protected. Personal Accident and Sickness Cover Claim Form

Your People, Protected. Personal Accident and Sickness Cover Claim Form Your People, Protected Personal Accident and Sickness Cover Claim Form Personal Accident and Sickness Cover/Claim Form 2 Personal Accident and Sickness Cover Claim Form IMPORTANT INFORMATION We act upon

More information

Personal Accident and Sickness Claim Form

Personal Accident and Sickness Claim Form Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Employer: Claimants Name: Job

More information

Funeral Insurance at ClearView. Product Disclosure Statement & Policy Wording

Funeral Insurance at ClearView. Product Disclosure Statement & Policy Wording Funeral Insurance at ClearView Product Disclosure Statement & Policy Wording 1 October 2011 About this document This document contains the Product Disclosure Statement (PDS) and policy wording and is designed

More information

EVIDENCE OF INSURABILITY COVERAGE DETAIL

EVIDENCE OF INSURABILITY COVERAGE DETAIL EVIDENCE OF INSURABILITY COVERAGE DETAIL This application consists of two parts: The Evidence of Insurability Coverage Detail form and Medical & Lifestyle Questionnaire. INSTRUCTIONS Plan Administrator:

More information

Personal Accident & Illness Application Form

Personal 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 information

Join GMHBA Transfer from an existing GMHBA membership Change my GMHBA cover

Join GMHBA Transfer from an existing GMHBA membership Change my GMHBA cover Application form September 2012 1. I wish to (please tick) Join GMHBA Transfer from an existing GMHBA membership Change my GMHBA cover GMHBA member number (existing members only) Cover or change of cover

More information

St.George Quick Cover

St.George Quick Cover St.George Quick Cover St.George Quick Cover is the fast and easy way to help protect the people you care about. Product Disclosure Statement and Policy Wording (PDS). Effective Date: 20 October 2014 Issued

More information

Federation Internationale De Motocyclisme (F.I.M.) Rider Personal Accident Insurance

Federation Internationale De Motocyclisme (F.I.M.) Rider Personal Accident Insurance Federation Internationale De Motocyclisme (F.I.M.) Rider Personal Accident Insurance Aon Risk Services are pleased to offer F.I.M Rider Personal Accident Insurance in accordance with the F.I.M s stipulated

More information

Personal Accident Claim Form

Personal Accident Claim Form Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Personal Accident Claim Form

More information

Change My Insurance Details Form

Change My Insurance Details Form Change My Insurance Details Form Please complete and return this form to: NESS Super, Locked Bag 20, Parramatta NSW 2124 Complete in pen using CAPITAL letters or type directly into this form and print

More information

Woolworths NSW Member Income Protection Form

Woolworths 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 information

PERSONAL INJURY CLAIM FORM

PERSONAL INJURY CLAIM FORM Office use only Policy Number: 0028332 Claim Number: s PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR TENPIN BOWLING AUSTRALIA V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised

More information

CORPORATE VOLUNTARY DIRECT DEBIT APPLICATION

CORPORATE VOLUNTARY DIRECT DEBIT APPLICATION CORPORATE VOLUNTARY DIRECT DEBIT APPLICATION 1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a CROSS. Start at the left of

More information

Federation Internationale De Motocyclisme (F.I.M.) Rider Personal Accident Insurance

Federation Internationale De Motocyclisme (F.I.M.) Rider Personal Accident Insurance Federation Internationale De Motocyclisme (F.I.M.) Rider Personal Accident Insurance Aon Risk Services are pleased to offer F.I.M Rider Personal Accident Insurance in accordance with the F.I.M s stipulated

More information

PLEASE DO NOT STAPLE.

PLEASE DO NOT STAPLE. YOUR APPLICATION 1. Please complete this form USING BLACK INK and write within the boxes in CAPITAL LETTERS. Mark appropriate answer boxes with a CROSS. Start at the left of each answer space and leave

More information

LIFE INSURANCE EXPRESS

LIFE INSURANCE EXPRESS LIFE INSURANCE EXPRESS Combined Product Disclosure Statement and Policy Document This product and Combined Product Disclosure Statement and Policy Document are issued by Suncorp Life & Superannuation Limited

More information

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE

CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE CLAIM FORM: AMATEUR SPORTS PERSONAL ACCIDENT INSURANCE THE ISSUE OF THIS FORM IS NOT AN ADMISSION OF LIABILITY PLEASE ENSURE You fully complete every question before your doctor completes his statement.

More information

Professionals Income Protection Plan

Professionals Income Protection Plan Customer Services Phone 1800 658 679 Fax 02 9234 6668 Email customer@ing.com.au Postal address Customer Services GPO Box 5306 Sydney NSW 2001 Website www.ing.com.au Professionals Income Protection Plan

More information

LIFE INSURANCE EXPRESS

LIFE INSURANCE EXPRESS LIFE INSURANCE EXPRESS Combined Product Disclosure Statement and Policy Document This product and Combined Product Disclosure Statement and Policy Document are issued by Suncorp Life & Superannuation Limited

More information

SMSF. Comprehensive life insurance cover for members of self managed super funds. Product Disclosure Statement

SMSF. Comprehensive life insurance cover for members of self managed super funds. Product Disclosure Statement SMSF Comprehensive life insurance cover for members of self managed super funds Product Disclosure Statement Issued: 18 April 2013 Contents About Insure Me Now 3 About Hannover 3 Explaining this Product

More information

BT Protection Plans Supplementary Product Disclosure Statement and Policy Addendum (SPDS)

BT Protection Plans Supplementary Product Disclosure Statement and Policy Addendum (SPDS) BT Protection Plans Supplementary Product Disclosure Statement and Policy Addendum (SPDS) Dated 1 July 2014 This SPDS is dated 1 July 2014 and supplements the information contained in the BT Protection

More information

sp rts Sports Coaching & Clinics Insurance Application Form Underwriting Australia Sports Leisure Licensed Clubs

sp rts Sports Coaching & Clinics Insurance Application Form Underwriting Australia Sports Leisure Licensed Clubs sp rts Underwriting Australia Insurance Application Form Sports Leisure Licensed Clubs Please use this application for occupations relating to the including: Sports Clinics Sports Coaches School Sports

More information

Life Insurance at ClearView. Product Disclosure Statement & Policy Wording

Life Insurance at ClearView. Product Disclosure Statement & Policy Wording Life Insurance at ClearView Product Disclosure Statement & Policy Wording 1 October 2011 About this document This document contains the Product Disclosure Statement (PDS) and policy wording and is designed

More information

Life Assurance. For Broker Use Only. Application Form. Please complete in all cases. Email address for communication: Contact details

Life 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 information

Personal Statement/ Member s Declaration Group Life including Salary Continuance

Personal Statement/ Member s Declaration Group Life including Salary Continuance 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 information

combined financial services guide, product DiSclosure statement and policy Wording

combined financial services guide, product DiSclosure statement and policy Wording combined financial services guide, product DiSclosure statement and policy Wording life insurance 28th october 2011 This document is a Combined Financial Services Guide, Product Disclosure Statement and

More information

Flexible Lifetime Super

Flexible Lifetime Super Issued ₁ July ₂₀₁₅ Flexible Lifetime Super Insurance fact sheet Registered trademark of AMP Life Limited ABN 84 079 300 379. This document is a fact sheet for the product disclosure statement (PDS) dated

More information

Personal Accident or Sickness Claim

Personal Accident or Sickness Claim INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Personal

More information

WA Super Insurance Guide

WA Super Insurance Guide MY SUPER APPROVED WA Super Insurance Guide The information in this document forms part of the WA Super Product Disclosure Statement, November 2013 You should read the PDS in conjunction with this Member

More information

LOAN PROTECTION INSURANCE CLAIM FORM

LOAN PROTECTION INSURANCE CLAIM FORM LOAN PROTECTION INSURANCE CLAIM FORM PO BOX 6156, NORTH SYDNEY 2059 PHONE: 1300 781 448 FAX: 02 8920 1275 E-MAIL: CLAIMS@MI-BIKE.COM.AU Please ensure that all questions are answered in full in as much

More information

Suncorp Life Protect Express. Combined Product Disclosure Statement and Policy Document

Suncorp Life Protect Express. Combined Product Disclosure Statement and Policy Document Suncorp Life Protect Express Combined Product Disclosure Statement and Policy Document Prepared on: 20 February 2015 Effective date: 30 March 2015 1.0 Important information This is the combined Product

More information

Suncorp Accidental Death Plan. Product Disclosure Statement

Suncorp Accidental Death Plan. Product Disclosure Statement Suncorp Accidental Death Plan Product Disclosure Statement Prepared on: 14 February 2014 Effective date: 12 March 2014 Important Information This is the Product Disclosure Statement (PDS) for Suncorp Accidental

More information

Application Form and Insurance Information

Application Form and Insurance Information Application Form and Insurance Information Family Day Care Australia Educator Insurance 9 Insurance Application Form C A O OFFICE USE ONLY Applicant Details Name of family day care coordination unit you

More information

MOTOR VEHICLE PROPOSAL FORM

MOTOR VEHICLE PROPOSAL FORM Commercial and Trucksure Pty Ltd As agent for the Insurer ABN: 78 078 661 220 AFSL: 238151 Level 6, 3 Spring Street Sydney NSW 2000 PO Box R1940 Royal Exchange NSW 1225 Telephone: (02) 9251 1155 Facsimile:

More information

BT Classic Investment Funds Additional and Regular Investments Request

BT Classic Investment Funds Additional and Regular Investments Request BT Classic Investment Funds Additional and Regular Investments Request BT Customer Relations 132 135 (8.00am 6.30pm Mon-Fri, Sydney time) The Responsible Entities for the Funds offered through BT Classic

More information

Life and Total and Permanent Disability Superannuation Insurance

Life 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 information

Insurance Request Form

Insurance 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 information

Personal Injury Claim Form

Personal Injury Claim Form ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815

More information

term life insurance AMP firstcare A simple and convenient way to protect yourself and your family s future Customer Information Brochure

term life insurance AMP firstcare A simple and convenient way to protect yourself and your family s future Customer Information Brochure AMP firstcare term life insurance A simple and convenient way to protect yourself and your family s future Customer Information Brochure You should read the following material carefully, especially the

More information

motor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle

motor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle motor vehicle insurance application for privately owned non-commercial vehicles (excluding motorcycles) motor vehicle CGU Insurance Limited ABN 27 004 478 371. An IAG Company. Please read the following

More information

PERSONAL ACCIDENT CLAIM FORM

PERSONAL ACCIDENT CLAIM FORM PERSONAL ACCIDENT CLAIM FORM Use this form when: A worker has suffered an accident, outside working hours and wishes to claim weekly benefits. This form should be completed as soon as it appears you will

More information

Application for health insurance. HCF Membership No. R20762. b) Choose your cover requirement (Please mark X )

Application for health insurance. HCF Membership No. R20762. b) Choose your cover requirement (Please mark X ) Application for health insurance (Please mark X ) Join HC health fund new to private health insurance (complete sections 1-8, excluding 7) Transfer to HC health fund from another fund (complete sections

More information