Application for increases without further medical evidence

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1 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 Disability (TPD) and/or Critical Illness benefit for a Life Insured to be increased without further medical evidence, in accordance with the terms and conditions of your policy. You should read your policy document carefully before signing this application. Your application to increase this insurance is not effective until MLC accepts this application and issues a revised schedule. Please make sure you have attached a copy of your premium quotation to this form. Your Duty of Disclosure Before you enter into a contract of life insurance with MLC, you have a duty, under the Insurance Contracts Act 1984, to disclose to MLC every matter that you know, or could reasonably be expected to know, is relevant to MLC 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 MLC before such a contract of life insurance is extended, varied or reinstated. Your duty, however, does not require disclosure of a matter: that diminishes the risk to be undertaken by MLC that is of common knowledge about which MLC knows or, in the ordinary course of business, ought to know for which your duty of compliance is waived by MLC. If you take out MLC Insurance (Super) the Trustee obtains life insurance from MLC on you. Because the Trustee is taking out a life policy at your request, the Trustee requires you to make full disclosure to it on the same basis. Non-disclosure If you fail to comply with your Duty of Disclosure and MLC would not have entered into the contract on any terms if the failure had not occurred, MLC may avoid the contract within three years of entering into it. If your non-disclosure is fraudulent, MLC may avoid the contract at any time. Even if MLC is entitled to avoid a contract of life insurance MLC may, within three years of entering into it, elect not to avoid it but reduce the sum for which you have been insured in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to MLC. Your Duty of Disclosure continues until the contract of life insurance has been accepted by MLC and a policy is issued. It also applies if the contract is extended, varied or reinstated. MLC Limited ABN AFSL Issuer of MLC Insurance MLC Nominees Pty Limited ABN AFSL RSE L Issuer of MLC Insurance (Super) Trustee for The Universal Super Scheme ABN R SFN

2 Eligibility to apply for an increase without further medical evidence For all increases to benefits without further medical evidence, you will need to provide proof of the event, and any additional financial evidence satisfactory to us to support the increase requested. See your PDS for eligibility requirements. You are not eligible to apply for an increase to your benefit without further medical evidence if you have made a claim or are entitled to make a claim under this policy. Please PRINT and COMPLETE sections 1 and 2, which will help us to identify you, the sections which relate to the changes you wish to make and the declaration. Unless otherwise stated, all change specified on this form will be applied to the policy(ies) where the policy number(s) have been provided. Section 1 Your policy details Policy number(s) Section 2 Current Policy Owner details Title Mr Mrs Miss Ms Other Middle name First name Surname Date of birth (DD/MM/YYYY) address Mobile phone number Trust / Partnership / Company name / Self Managed Super Fund Trustee, individual, director or secretary Page 2 of 16

3 Section 3 Life Insured details Person whose Life is insured Mr Mrs Miss Ms Dr Other: First name Surname Date of birth (DD/MM/YYYY) NAB customer number (NAB Adviser use only) Postal Address for correspondence Address Suburb Postcode State Contact Details Home telephone Best contact time Day(s) : am/pm Work telephone Best contact time Day(s) : am/pm Mobile Fax Please fill in the following sections for your application Income Protection 4 and 7 Life Cover, TPD and Critical Illness due to a Personal event 5 and 7 due to a Business event 6 and 7 Page 3 of 16

4 Section 4 Increases to Income Protection This insurance is being increased because the Life Insured: has married has divorced has completed an undergraduate degree at a Government recognised university has received an increase in their Earnings of at least 10% in the previous 12 months has a child who has started secondary school has taken out a mortgage to purchase their home has increased a mortgage to improve their home or their spouse has given birth to or adopted a child Income Protection Worksheet To confirm the Life Insured s eligibility we need you to complete this form to ensure that the maximum benefit is not exceeded. After you increase your Income Protection monthly benefit without further medical evidence, your monthly benefit cannot exceed the lesser of (A), (B) and (C): Your current monthly benefit (i) $ 20% of your monthly benefit (ii) $ Total of (i) + (ii) = (A) $ Maximum monthly benefit across all income protection insurance on your life held with MLC = (B) $ 30,000 Maximum insurable amount: Your current annual Earnings (refer to the Earnings definition below) 75% of first $320,000 $ 50% of next $320,001 $560,000 $ 20% of next $560,001 $2,360,000 $ 12 = (C) $ Earnings If you are self employed (you directly own all or part of a business or practice), Earnings means the income of the business or practice generated by your personal efforts after the deduction of your appropriate share of business or practice expenses in generating that income. If you are an employee (you do not directly own all or part of a business or practice), Earnings means the total remuneration paid by the employer to you, including salary, commission, fees, regular bonuses, regular overtime, fringe benefits and regular superannuation contributions paid by the employer on your behalf. Whether you are self employed or an employee, Earnings do not include investment income, and are calculated before tax. The maximum allowable increase is the lesser of (A), (B) and (C) = (D) $ By how much would you like to increase the Income Protection benefit: $ The Policy Owner and the Life Insured make the following declarations and confirmation: I understand and agree that: in the event of a claim, MLC may request financial documents from me to support this increase to my monthly benefit I confirm that: as the Life Insured, my current Earnings support an increase to the monthly benefit (see above Maximum insurable amount) Page 4 of 16

5 Section 5 Increases to Life Cover, TPD and Critical Illness due to Personal Event This insurance is being increased because the Life Insured: has married has divorced has completed an undergraduate degree at a Government recognised university has received an increase in their Earnings of at least 10% in the previous 12 months has a child who has started secondary school or their spouse has given birth to or adopted a child has taken out a mortgage to purchase their home has increased a mortgage to improve their home Go to Personal events A Go to Personal events B Personal events A: Birth, adoption, marriage, divorce, undergraduate degree completed, increase in Earnings of at least 10% or child starts secondary school Life Cover worksheet Original Life Cover benefit $ You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following: 25% x original Life Cover benefit (A) $ maximum increase (B) $ 200,000 The maximum allowable increase is the lesser of (A) and (B) $ TPD worksheet Original TPD benefit $ You may apply to increase the TPD benefit without further medical evidence by the lesser of the following: 25% x original TPD benefit (A) $ maximum increase (B) $ 200,000 The maximum allowable increase is the lesser of (A) and (B) $ Critical Illness worksheet (MLC Insurance) Original Critical Illness benefit $ You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following: 25% x original Critical Illness benefit (A) $ maximum increase (B) $ 200,000 The maximum allowable increase is the lesser of (A) and (B) $ By how much would you like to increase the: Life Cover benefit $ TPD benefit $ Critical Illness benefit $ Page 5 of 16

6 Section 5 Increases to Life Cover, TPD and Critical Illness due to Personal Event (continued) Personal events B: Home loans and home improvement loans Life Cover worksheet Original Life Cover benefit $ You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following: 50% x original Life Cover benefit (A) $ value of new mortgage (B) $ value of latest increase to existing mortgage (C) $ maximum increase (D) $ 200,000 The maximum allowable increase is the lesser of (A), (B), (C) and (D) $ TPD worksheet Original TPD benefit $ You may apply to increase the TPD benefit without further medical evidence by the lesser of the following: 50% x original TPD benefit (A) $ value of new mortgage (B) $ value of latest increase to existing mortgage (C) $ maximum increase (D) $ 200,000 The maximum allowable increase is the lesser of (A), (B), (C) and (D) $ Critical Illness worksheet (MLC Insurance) Original Critical Illness benefit $ You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following: 50% x original Critical Illness benefit (A) $ value of new mortgage (B) $ value of latest increase to existing mortgage (C) $ maximum increase (D) $ 200,000 The maximum allowable increase is the lesser of (A), (B), (C) and (D) $ By how much would you like to increase the: Life Cover benefit $ TPD benefit $ Critical Illness benefit $ Page 6 of 16

7 Section 6 Increases to Life Cover, TPD and Critical Illness due to Business Event This insurance is being increased because: the Life Insured is a key person in your business and their value to the business has increased (outside Super only) it forms part of a written ownership (buy/sell), share purchase, or business continuation agreement, and the Life Insured is a partner, shareholder or unit holder in the business, and the Life Insured s financial interest in the business has increased the business debt the life insured is responsible for has increased Go to Business events A Go to Business events B Go to Business events C Business events A: Revenue protection / key person The value of the Life Insured as a key person is defined as the total of their remuneration package for each year excluding discretionary benefits, plus their share of net profit distributed by the business in that year. Has the basis of measuring this remuneration been consistent over the past 3 years? Yes No Please provide details Life Cover worksheet (MLC Insurance only) Original Life Cover benefit (a) $ Life Cover benefit 1 year ago (b) $ Value of key person 1 year ago (c) $ Value of key person now (d) $ Value of key person 3 years ago (f) $ You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following: 5 x increase, averaged over prior 3 years (ie 5 x (d - f) / 3) (iii) $ Page 7 of 16

8 Section 6 Increases to Life Cover, TPD and Critical Illness due to Business Event (continued) TPD worksheet (MLC Insurance only) Original TPD benefit (a) $ TPD benefit 1 year ago (b) $ Value of key person 1 year ago (c) $ Value of key person now (d) $ Value of key person 3 years ago (f) $ You may apply to increase the TPD benefit without further medical evidence by the lesser of the following: 5 x increase, averaged over prior 3 years (ie 5 x [d - f] / 3) (iii) $ Critical Illness worksheet (MLC Insurance only) Original Critical Illness benefit (a) $ Critical Illness benefit 1 year ago (b) $ Value of key person 1 year ago (c) $ Value of key person now (d) $ Value of key person 3 years ago (f) $ You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following: 5 x increase, averaged over prior 3 years (ie 5 x [d - f] / 3) (iii) $ By how much would you like to increase the: Life Cover benefit $ TPD benefit $ Critical Illness benefit $ Page 8 of 16

9 Section 6 Increases to Life Cover, TPD and Critical Illness due to Business Event (continued) Business events B: Ownership protection, buy/sell, share purchase The value of the financial interest of the Life Insured in any one year will be based on their share of the net value of the business at the end of that year ( net meaning the value of the business less liabilities). The level of the Life Cover, TPD and Critical Illness benefit (as applicable) for the Life Insured must be equal to, or less than, the net value of the Life Insured s share of the business. What method of valuation has been used for valuing the Life Insured s share of the business? Net Asset Backing Capitalisation of Earnings Book Value Other (please specify) Has there been a change to the industry/type of business the Life Insured is engaged in? No Yes Please advise new industry/type of business of Life Insured below. Life Cover worksheet Original Life Cover benefit (a) $ Life Cover benefit 1 year ago (b) $ Value of Life Insured s share of the business 1 year ago (c) $ Value of Life Insured s share of the business now (d) $ Value of Life Insured s share of the business 3 years ago (f) $ You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following: increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $ Page 9 of 16

10 Section 6 Increases to Life Cover, TPD and Critical Illness due to Business Event (continued) TPD worksheet Original TPD benefit (a) $ TPD benefit 1 year ago (b) $ Value of Life Insured s share of the business 1 year ago (c) $ Value of Life Insured s share of the business now (d) $ Value of Life Insured s share of the business 3 years ago (f) $ You may apply to increase the TPD benefit without further medical evidence by the lesser of the following: increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $ Critical Illness worksheet Original Critical Illness benefit (a) $ Critical Illness benefit 1 year ago (b) $ Value of Life Insured s share of the business 1 year ago (c) $ Value of Life Insured s share of the business now (d) $ Value of Life Insured s share of the business 3 years ago (f) $ You may apply to increase the Critcal Illness benefit without further medical evidence by the lesser of the following: increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $ By how much would you like to increase the: Life Cover benefit $ TPD benefit $ Critical Illness benefit $ Page 10 of 16

11 Section 6 Increases to Life Cover, TPD and Critical Illness due to Business Event (continued) Business events C: Asset Protection (Loan Guarantee) The part of the Business Loan the life insured is responsible for in any one year will be calculated on their share of the Business Loan at the end of that year. What proportion of the Business loan is the Life Insured responsible for? % Life Cover worksheet Original Life Cover benefit (a) $ Life Cover benefit 1 year ago (b) $ Business Loan amount the Life Insured was responsible for 1 year ago (c) $ Business Loan amount the Life Insured is responsible for now (d) $ Business Loan amount the Life Insured was responsible for 3 year ago (f) $ You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following: increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $ TPD worksheet Original TPD benefit (a) $ TPD benefit 1 year ago (b) $ Business Loan amount the Life Insured was responsible for 1 year ago (c) $ Business Loan amount the Life Insured is responsible for now (d) $ Business Loan amount the Life Insured was responsible for 3 year ago (f) $ You may apply to increase the TPD benefit without further medical evidence by the lesser of the following: increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $ Page 11 of 16

12 Section 6 Increases to Life Cover, TPD and Critical Illness due to Business Event (continued) Critical Illness worksheet Original Critical Illness benefit (a) $ Critical Illness benefit 1 year ago (b) $ Business Loan amount the Life Insured was responsible for 1 year ago (c) $ Business Loan amount the Life Insured is responsible for now (d) $ Business Loan amount the Life Insured was responsible for 3 year ago (f) $ You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following: increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $ By how much would you like to increase the: Life Cover benefit $ TPD benefit $ Critical Illness benefit $ Page 12 of 16

13 Section 7 Declarations Read this section carefully before signing I understand and agree that: (a) I have read the Duty of Disclosure set out on page 1. I understand that, until MLC accepts this application and issues a revised Schedule, I have a duty to disclose every matter which I know or could reasonably be expected to know is relevant to MLC s acceptance of this application and that if I fail to comply with my duty of disclosure MLC may (as permitted by law) avoid the increase or reduce the benefits under it; (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) The answers to the questions above are true and complete; If any answers to questions in this application are not in my own handwriting, I certify I have checked them and they are correct; No increase to insurance is effective until MLC accepts this application and issues a revised Schedule; The terms and conditions of any increase in the Income Protection, Life Cover, TPD and/or Critical Illness benefit apply as described in the relevant policy document and in any written notification of changes subsequent to the relevant policy document being issued; For Income Protection in the first 12 months after an increase under this benefit, the amount of the increase (excluding any increases due to Inflation Proofing) covers the Life Insured for Total Disability and Partial Disability caused by an accident only; During the first six months after certain increases, the increased amounts cover you only for the following specified events caused by an Accident: Life Cover: for marriage, divorce or Mortgage, the increase covers only death. Critical Illness: for marriage, divorce or Mortgage, the increase covers only death and critical conditions. TPD: whatever the reason for increase, the increase covers only TPD. The increased insurance also does not cover you for any TPD caused by sickness or injury that first happened within six months before the increase. If I have increased the Life Cover, TPD and /or Critical Illness benefit for the Life Insured in the last 13 months and that Life Insured commits suicide MLC will only pay the Life Cover, TPD and/or Critical Illness benefit applicable before the increase; If the Life Insured has made a claim or is entitled to make a claim under this policy the Life insured is not eligible to apply for an increase without further medical evidence; I have attached certified proof of birth, adoption, marriage, divorce, undergraduate degree, secondary school commencement, increase in Earnings, home loan details or business event. Please see page 14 for an explanation of certified proof; If I have provided my address for the purpose of receiving communications from MLC, I acknowledge my personal and sensitive information may be sent to that address. Signature of Life Insured Date (DD/MM/YYYY) Signature(s) of Policy Owner(s) You don t need to complete this part if the Policy Owner is the Life Insured or if this is an MLC Insurance Super policy. Parent or Guardian if Life Insured is under 16 years of age Where a company is the proposed owner of a policy there is no need for the company seal to be affixed. In the case where the Policy Owner is a company: a) Two directors or a director and company secretary are to sign; or b) In the case of a sole director proprietary company only, the sole director is to sign. The director must indicate that he/she is the sole director and sole secretary of the company. Policy 1 Signature(s) of Policy Owner(s) Date (DD/MM/YYYY) Policy 2 Signature(s) of Policy Owner(s) Date (DD/MM/YYYY) Date (DD/MM/YYYY) Date (DD/MM/YYYY) Sole director and sole secretary (indicate by ticking box) Sole director and sole secretary (indicate by ticking box) Page 13 of 16

14 Proof required to increase your benefit without medical evidence Increases as a result of birth, adoption, marriage, divorce, undergraduate degree completion or child starting secondary school You are required to provide certified proof of the event. Certified proof is a copy of the original that is signed by one of the following people as a true and complete copy of the original. Justice of the peace Solicitor/barrister Police officer Registered medical practitioner Full time teacher at a school or tertiary education institution with five years service Bank, building society or credit union officer with five years service Postal manager Dentist Pharmacist Minister of religion designated as an authorised marriage celebrant Registered nurse or enrolled nurse with five years service Registered accountant Increases as a result of increase in Earnings You are required to provide proof of the increase in Earnings. This may include: Letter from employer Tax returns Any other financial evidence we require Increases as a result of a mortage or increase to an existing mortage You are required to provide proof of your home loan details. This may include: Mortgage deeds or documents Loan certificates Increases as a result of business events You are required to provide proof of the business event. This may include: Company minutes Ownership (buy/sell) agreements Audited company accounts Tax returns Loan documents or certificates Any other financial evidence we require Page 14 of 16

15 This section for Financial Adviser use only This section must be completed address (contact for this application) Financial Adviser s instructions (Complete details relevant to this application) Financial Adviser 1 This section is to be completed by the Servicing Adviser. The Servicing Adviser will receive all correspondence for the policy. Name of Financial Adviser Financial Adviser 2 Name of Financial Adviser MLC Financial Adviser No. Mobile phone MLC Financial Adviser No. Mobile phone Telephone number Telephone number Fax number Fax number address address Distribution fee split % Distribution fee split % NAB Financial Planning use only: FI/FN Number Referring BUID Number Referring Banker s Name Special Instructions and Underwriting Reference Number Page 15 of 16

16 Registered Office for MLC Limited and MLC Nominees Pty Limited Ground Floor Miller Street North Sydney NSW 2060 Website: mlc.com.au Telephone: (inside Australia) (outside Australia) Fax: (inside Australia) (outside Australia) Postal address: PO Box 200 North Sydney NSW M0612 Page 16 of 16

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