Application for payment of a disablement or terminal illness benefit

Transcription

1 Application for payment of a disablement or terminal illness benefit Use this form if you wish to apply for: a total and permanent disablement (TPD) insurance benefit a terminal illness insurance benefit the release of your account balance due to permanent incapacity or a terminal illness medical condition (if you do not have insurance cover). Specific documents are required to enable your application to be assessed for any of these benefits. You can also use this form to advise your payment instructions if your application has already been accepted. Please use a dark pen and CAPITAL letters. Insert ( ) when you have to choose an option. You can also fill in this form online, print it and send it to us. Forms are located on our website at firststatesuper.com.au/ forms. If you have any questions, please call us on Your personal details Member number Account number Date of birth Title Given name(s) Residential address Last name F S S U Suburb State Postcode Postal address (if different to residential address) Suburb State Postcode Daytime contact number Mobile number M F (for security reasons, please ensure that your nominated address is your personal address and not a role-based address such as employee_title@company.com.au) See Important information about your benefit in the Notes for more information. 2. Your employer / employment details Only complete this section if you are claiming your benefits under TPD or permanent incapacity, NOT terminal illness. Employer name It is important to put a date in the Date of last super contribution field. See Notes Section 2 for more details. What was the date you were last physically able to carry out the normal duties of your occupation Your last day you were physically at work Date of last super contribution (if known) (DD-MM-YYYY) Contribution amount (if known) $,. Has your employment been terminated Yes No Employer contact person Employer phone number address of employer contact person page 1 of 7

2 Important! You have four payment options: 1. Cash all or part of your benefit 2. Roll over/transfer all or part of your benefit to another super fund 3. Transfer all or part of your benefit to a First State Super income stream 4. Defer part or all our your entire benefit. 3. Your payment options Option 1: Cash all or part of your benefit Please mark to indicate your choice I wish to cash my entire benefit (my account balance plus any insurance component) I wish to cash my account balance but leave any insured component in First State Super I wish to cash the insured component only, leaving my account balance in First State Super I would like to cash the following (gross) amount of my benefit: $,. Cash payment details (please mark to indicate your choice) Post a cheque to my residential address Post a cheque to my postal address (gross) For more information about your payment options, see Notes Section 3. Pay direct to my bank account shown below. The account must be in your name and you must provide your account details, together with a copy of your statement or passbook showing your full name, address and account details. Payments cannot be made to offshore bank accounts. Account name BSB number Bank account number Important! The certification period for the release of insured benefits under terminal illness is 12 months, while the release of super benefits under terminal illness has an extended certification period of 24 months. A full withdrawal of your super benefits when you meet the 24 month certification period will result in the loss of your insurance cover and the potential to claim under the terminal illness provisions for insurance. Name of financial institution Branch Option 2: Roll over/transfer all or part of your benefit I wish to roll over/transfer my whole benefit; OR I wish to roll over/transfer part of my benefit: $,. Payment will be made to the rollover fund you nominate to an account in your name. A payment to a self-managed superannuation fund will be made by cheque to the fund s registered name and mailed to the registered address recorded on the Government s Super Fund Lookup website at Where the SMSF fund states is not clear, we may require additional documentation to process the rollover. Name of fund you are transferring to Fund's phone number Fund ABN (gross) Unique superannuation identifier (USI) (not application for transfers to SMSFs) Fund member number (not applicable for transfers to SMSFs) page 2 of 7

3 For more information about your payment options, see Notes Section Your payment options (continued) Option 3: Transfer all or part of your benefit to a First State Super income stream To transfer into the First State Super income stream, you will also need to complete the application form at the back of the income stream Product Disclosure Statement. You need a minimum of $20,000 to open an income stream account. Please mark to indicate your choice: Full transfer OR My balance minus $1,500 OR Partial transfer* of $,,. * If you are requesting a partial transfer, and the amount you wish to transfer does not allow $1,500 to remain in your account, then the amount released will be your account balance less $1,500. Please mark to indicate your choice: I declare that I meet the Superannuation Industry (Supervision) Act of 1993 definition of permanent incapacity I declare that I satisfy the criteria for a terminal illness condition Option 4: Defer part or all of your benefit payment For more information about deferring part or all of your benefit, see Notes Section 3. Please mark to indicate your choice: I wish to defer all of my benefit entitlement (my account balance plus any insurance component) I wish to defer part of my benefit. Please retain $,. in my account * If you are requesting a partial deferral, and the amount you wish to transfer does not allow $1,500 to remain in your account, then the amount released will be your account balance less $1,500. For more information about your proof of identity, see Notes Section Proof of identity You must provide certified proof of identity before your funds will be released, unless you have already provided this information. If any of your personal details (i.e. name, postal or address, bank account etc.) have changed since you provided the CPOI you will need to resubmit updated certified proof of identity to us. We can request current certified proof of identification if this is considered necessary. For information on how to prove your identity and certify documents, see Notes Section Privacy The personal information you provide on this form is collected by and held for First State Super by the fund administrator, Pillar Administration, in accordance with the Australian Privacy Principles of the Privacy Act 1988 (Cth), for the purpose of administering your account and providing you with services associated with your fund membership. For further information about how your personal information is handled, please call us on or visit firststatesuper.com.au/privacy to view the privacy policy (a hard copy of the policy may also be provided on request). The policy contains information about how you may access and seek correction of your personal information, how you may complain about a breach of your privacy and other important information about how your personal information is collected, used and disclosed. page 3 of 7

4 If you would like more information, call customer service on before you submit this application. Your application will be delayed if you do not sign and date this declaration. 6. Declaration This section requires you to formally acknowledge that you have received and understood the information provided to allow you to make an informed decision on the payment or transfer of your benefit entitlement. I have been given sufficient information to make an informed decision about the payment of my benefit from the Fund. I certify that the details given by me in this form are true and correct. I have read and understood the First State Super privacy policy. Please sign and date form here. Signature Date (DD-MM-YYYY) Name (print in CAPITAL letters) Send the form to this address. 7. Where to send your completed form Return the completed form to First State Super PO Box 1229 WOLLONGONG NSW If you have any questions, please call us on page 4 of 7

5 Notes for completing the application for payment of a disablement benefit form Forms are located on our website at firststatesuper.com.au/forms. You can type data directly into these forms, print them and send them to us. If you prefer to write on the forms, please use a dark pen and print clearly. Important information about your benefit Insurance cover If you are an insured member and you are applying for full payment or transfer of your benefit entitlement to another fund or to a First State Super income stream, your insurance cover will cease when the payment from the fund is made. If you are an insured member and you are applying for part payment of your benefit entitlement, either paid to you or rolled over to another complying superannuation fund, your insurance will cease when you elect to cancel your insurance cover, reach age 70 if you have death and TPD cover or death only cover or reach age 65 if you have income protection cover, have insufficient funds to pay the premiums or you transfer or are paid your entitlement from the fund. Police Blue Ribbon or Ambulance Officers TPD claims Members of Police Blue Ribbon Super and Ambulance Officers Super should refer to specific insurance claim fact sheets available from the First State Super website or customer service. First State Super insurance providers From time to time First State Super changes its insurance providers. Based on the information provided by you when you initiated your claim, the relevant insurance claim forms have been provided to you. During the course of the assessment of your claim it may be identified that the liability to assess your claim lies with a previous or later insurer. In the event that this happens there is minimum interruption to the assessment process. Total and permanent disablement (TPD) insurance benefit To apply for a TPD insurance benefit, you must complete this form and arrange for completion of the following insurance claim forms: Member s Statement (to be completed by you) Attending Doctor s Statement TPD (to be completed by your treating medical doctor at the time of your disablement) Employer s Statement (to be completed by your employer at the time you ceased work due to your disablement). Please refer to the fact sheet Insurance and superannuation claims (excluding death claims) for details of the claims assessment process and the definition of TPD that will apply to your claim. There are separate fact sheets for members of the Police Blue Ribbon and Ambulance Officers insurance arrangements so please refer to the fact sheet that applies to your particular circumstances. If your claim for a TPD insurance benefit is accepted and the Trustee of First State Super ( Trustee ) is satisfied that you meet the criteria for a condition of release as a result of permanent incapacity, your account balance and insurance proceeds can be released to you in accordance with your payment instructions. Terminal illness insurance benefit You may apply for a terminal illness insurance benefit if you have death and TPD, or death only insurance cover and if two doctors (one of whom is a specialist in your illness) certify in writing that despite reasonable medical treatment, you are suffering an illness that will lead to your death within 12 months of the date of the certification. To apply for a terminal illness insurance benefit, you must complete this form (FSS 015) and arrange for completion of the following insurance claim forms: Terminal Illness claim form (to be completed by you) Attending Doctor s Statement (Terminal Illness) Attending Specialist s Statement (Terminal Illness). We will send you all the forms you need to complete at the time you make your claim. Releasing your benefit due to permanent incapacity or terminal illness medical condition if you do not have insurance cover a) Permanent incapacity If you do not have any insurance cover you can apply for the early release of your account balance on the basis of permanent incapacity. To apply on this basis, you must have ceased gainful employment and complete this form and provide two Confidential medical report on permanent incapacity forms completed by two medical practitioners. If the Trustee is reasonably satisfied that you are unlikely, because of physical or mental ill health, to ever again engage in gainful employment for which you are reasonably qualified by education, training or experience your account balance will be released as per your payment instructions. b) Terminal illness If you do not have any insurance cover, you can apply for the release of your account balance on the basis of a terminal medical condition. To apply on this basis, you must arrange for two Confidential medical report on terminal illness forms to be completed by two doctors (one of whom should be a specialist practising in an area relating to the illness or injury) certifying in writing that despite reasonable medical treatment, you are suffering an illness that will lead to your death within 24 months of the date of the certification. There is no requirement that you must have ceased employment. Further information Further information can be obtained from the relevant to your membership category and the following fact sheets: Insurance and superannuation claims (excluding death claims) and Super taxes, caps, payments, thresholds and rebates. You may request any information necessary to understand your benefit entitlements from First State Super. This might include exit and other fees, insurance cover types and amounts or information regarding investment options. To obtain any further information or if you need information in relation to the documentation that has been sent to you in relation to your claim please contact customer service on or visit the website firststatesuper.com.au. page 5 of 7

6 1. Your personal details address The address you provide will replace any address we currently hold for you. For security reasons, please ensure that your nominated address is your personal address and not a role-based address such as employee_title@company.com.au. 2. Your employer details Date of last super contribution If you don t put a date in the Date of your last super contribution field, we will pay out your account within our normal processing time frame. If we receive another contribution from your employer, another account will be created. You will have to complete a new benefit payment form if you want to withdraw this money. 3. Your payment options Cash payment details Payment will be made to your current postal address if you do not complete the account details AND provide a copy of your statement or passbook that contains your full name, address and account details matching the banking details on your application form. Payments cannot be made to offshore bank accounts. Transfers to self-managed super funds Before processing a rollover, we have to ensure that the fund to which the payment is being made is a complying superannuation fund under the Superannuation Industry (Supervision) Act We do this by checking the Government s Super Fund Lookup website at To verify these details and ensure the fund is complying, we may require additional documentation. Deferring your benefit If deferring part or all of your benefit, you will need to reapply when you wish to access your benefit entitlement. Please note that partial deferral is subject to the part payment rule where the minimum amount retained in your account must be at least $1,500. Please also see the note on page 2 regarding the differing certification periods for terminal illness for the release of super and for the release of insurance cover. 4. Proof of identity (POI) You must provide certified proof of identity before your funds will be released, unless you have already provided this information. If any of your personal details (name or address) or your bank account details have changed, you will need to resubmit updated certified proof of identity documents to us. Providing certified proof of your identity is a three-step process: 1 Collect your originals Collect your proof of identity document(s). We have listed the documents you can use below. You can provide: Either: A certified copy of one of the following documents: current Australian state/territory driver s licence with your photograph Australian passport current card issued under a state or territory for the purpose of providing a person s age containing a photograph of the person current foreign passport or similar travel document containing a photograph and the signature of the person*. 2 Photocopy your originals Photocopied originals must be properly certified. Or: One certified document from this list: an Australian birth certificate or extract issued by a state or territory a citizenship certificate issued by the Commonwealth a current Centrelink pension card that entitles you to receive financial benefits AND 3 Have your photocopies certified Take your photocopies and your original documents to a person who can certify documents. A list of authorised certifiers and certification guidelines is included under Certification of personal documents. One certified document from this list: a notice issued by the ATO within the last 12 months that shows your name and current residential address and records an amount payable to or by you e.g. your last tax return a notice issued by a local council or utilities provider in the last three months showing the provision of services to you and your current residential address e.g. rates notice, electricity or water bill a notice issued by Commonwealth, state or territory government within the last 12 months showing your name and current residential address and the provision of financial benefits to you e.g. Centrelink letter. * Documents not written in English must be accompanied by an English translation prepared by an accredited translator. page 6 of 7

7 4. Proof of identity (Continued) Have you changed your name? If you have changed your name, you will need to provide one of the following certified documents: marriage certificate or certificate of registration (if you are on the relationship register) issued by the Births, Deaths and Marriages Registration Office (ceremonial certificates cannot be accepted) deed poll or change of name certificate from the Births, Deaths and Marriages Registration Office. If you have reverted to your maiden name on divorce, we will require a divorce certificate and a link document such as your marriage certificate showing your original maiden name. Certification of personal documents All copied pages of original POI documents (including any change of name documents) need to be certified as true copies by an authorised person with the appropriate Australian qualifications or registration (see below) who cannot be the owner or addressee of the document. The authorised person must sight the original and the copy to ensure both documents are identical, then make sure all pages have been certified by writing 'I certify that this document is a true copy of the original', followed by their signature, printed name, qualification (e.g. justice of the peace, Australia Post employee, etc.) and date. The following people can certify copies of the originals: police officer Australia Post employee in charge of an office providing postal services (charges may apply) Officer or an authorised representative of an Australian Financial Services Licensee (AFSL) with two or more years continuous service medical practitioner legal practitioner pharmacist justice of the peace magistrate nurse optometrist dentist chiropractor physiotherapist psychologist veterinary surgeon full-time teacher employed at a school or tertiary institution. Samantha Sample has provided a copy of her identification that includes her signature, full name, date of birth and current residential address. The authorised person has sighted the original identification and confirmed that the copy is a true copy. Details for the authorised person to include are full name, qualification, registration number (if applicable), date and signature. Samantha SAMPLE 123 ANY ST SUBURB NSW 2000 Licence No Licence Class C Driver Licence SAMPLE Donor A Conditions S Date of Birth 01 JAN 1980 "I certify that this document is a true copy of the original." Name: Kate Anderson Qualification: JP Registration no: Date: 31 March 2016 Card Number Expiry 01 JAN 2020 page 7 of 7

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