Use this form: To apply to join the superannuation scheme SuperLife as an Individual Member. Complete and send the form to SuperLife Limited.

Transcription

1 Membership form SuperLife superannuation scheme (AS/1068) Use this form: To apply to join the superannuation scheme SuperLife as an Individual Member. Complete and send the form to SuperLife Limited. SL Privacy Act This form collects personal information that is needed from you in connection with applying to join SuperLife. All information is being received, collected and held by SuperLife Limited on behalf of SuperLife Trustee Limited, PO Box 8811, Symonds Street, Auckland SuperLife Limited may pass this information to the Trustee and SuperLife s administrators, insurers and advisers. You can see and correct this information, subject to the provisions of the Privacy Act Your details First names: Surname: Preferred name: Title (Mr, Mrs, Ms, Miss, Dr): Male Female Date of birth: (dd/mm/ccyy) Phone: Home address: Town/city: Postal address (if different): Post code: Post code: IRD number: - - (You must enter your IRD number) PIR ( Prescribed investor rate ): 10.5% 17.5% 28% Your PIR will be 28% unless you tell us that you qualify for a 10.5% or 17.5% rate - see the PIR guide for more information. You beneficiaries On your death, any benefit will be paid to the individuals as you nominate, or your estate, or a family trust. You can change your nomination at any time by advice in writing to SuperLife Limited. If I die, the death benefit, i.e. my savings and any life insurance, should be paid to: (tick one) To the following people in the percentages shown: Title Name Date of birth Relationship (Mr, Mrs, Ms, Miss) (dd/mm/ccyy) Savings account % share Life insurance % share Total must be 100% 100% 100% or or My family trust. Enter name of trust: My estate 01

2 Savings Complete sections 1, 2 and 3 as appropriate. If you choose investment option 3.11 also complete section 4. Then sign the form on page Regular savings amount I want to contribute regular savings of: $ each month. I have attached a direct debit authority form. 2. Initial lump sum amount (if any) I attach a cheque/have transferred by internet banking ( ), to make a lump sum contribution of $. Cheques should be payable to SuperLife. 3. Investment strategy Your savings will be invested in the Default strategy (SuperLife 60 ), unless you choose differently from the range of options available. If you want an alternative investment strategy, choose one of the 11 strategy options below. If you choose the My mix option, you must then create your own investment strategy of the 22 Funds. Tick one Investment strategy to make your investment choice. Age Steps 1 AIM 2 SuperLife 30 3 SuperLife 60 4 SuperLife 80 Investment strategy option 5 AIM First Home /AIM myfuturefund 6 the D fund 7 smartconservative 8 smartbalanced 9 smartgrowth 10 Ethica. 11 My Mix. Future monthly contributions Initial lump sum If you tick option My Mix you must enter the $ amount, or the percentage of each contribution, that you want to put in each of the Funds in section 4 over the page. 02

3 4. My Mix strategy If you ticked investment option 11 under section 3, i.e. My Mix, then you must complete this section, otherwise leave it blank. $ or % $ or % Managed Funds Sector Funds ETF Funds Total SuperLife Income SuperLife 30 SuperLife 60 SuperLife 80 SuperLife 100 Ethica Cash NZ bonds OS bonds OS Non-govt bonds Property NZ shares Australian shares OS shares currency hedged OS shares (unhedged) Emerging markets Gemino UK Cash UK Income UK Shares/Property NZ Dividend ETF NZ 50 Portfolio ETF NZ Top 10 ETF NZ MidCap ETF Aust Top 20 Leaders ETF Aust Dividend ETF Aust Financials ETF Aust Property ETF Aust Resources ETF Aust MidCap ETF Total World ETF US S&P 500 ETF Europe ETF Asia Pacific ETF US Growth ETF US Value ETF US MidCap ETF US Small ETF Emerging Markets ETF Auto rebalancing of My Mix The standard practice is that your SuperLife Account balances will, from time to time, be rebalanced to maintain the overall strategy in line with your chosen investment strategy. If you do not want to have the standard automatic rebalancing, and you have chosen the My Mix option, tick the box below. Otherwise, leave it blank. If you have chosen an investment strategy besides My Mix, the option not to have the auto rebalancing does not apply. I do not want auto rebalancing to apply to my Accounts of my chosen My Mix strategy. Note: The Total if entered as $ must equal either the regular contribution or the initial lump sum. The Total if entered as % must equal 100%. 03

4 Your agreement I confirm that I have received an investment statement for SuperLife. I apply to join SuperLife. I authorise SuperLife to direct debit the savings, insurance premiums and associated fees (as applicable), from my bank account each month that I choose from time to time under SuperLife. I understand that SuperLife will send me statements and other communication materials by , to the address advised above. I agree to be bound by SuperLife s trust deed and rules made by the Trustee from time to time. Your signature: Date: (dd/mm/ccyy) 04

5 Insurance Complete sections A, B, C and D as appropriate, for the insurances you wish to apply for and sign the form on page 6. Name: A. Health questions Complete this section if you are applying for a life insurance and/or a disability income protection insurance benefit. If you are unsure, it is better to answer yes. If you answer no and your answer isn t right, the insurance company can refuse to pay out your insurance when you make a claim. 1. Have you been away from work for five (or more) days in a row in the past month because of sickness or injury? 2. Have you been told by your doctor that you have a terminal illness which means that you have 12 months or less to live? 3. Have you sought medical advice in the month before completing this application (tick one) Yes No Note: if you are joining SuperLife as an Individual Member and for some Employer Members and Spouse/Partner Members, you will need to complete a personal health statement from the insurance company. We will send you a personal health statement if it is applicable. B. Life insurance Complete this section if you are applying for a death, or death and total & permanent disablement lump sum benefit. Amount of insurance I want death cover of $ and total & permanent disablement cover of $ (can t be more than the amount of death cover) g Premium basis I want the premium rates for my life insurance to change (tick one): each 1 April each 5 years each 10 years Smoking status Do you smoke, or have you smoked in the last 12 months? (tick one) C. Disability income protection insurance Yes No Complete this section if you are applying for a disability income protection insurance benefit. Amount of income cover I want disability income cover each year of Waiting period $ a year (Minimum is $5,200 each year, maximum is 55% of gross pay) G I want the waiting period to be (tick one): 1 month 3 months 6 months Benefit period I want the benefit period to be for(tick one): 2 years 5 years to age 65 Employer statement I have enclosed the employer statement. 05

6 D. Medical insurance Complete sections 1 or 2 and sections 3 and 4, if you are applying for a medical insurance benefit through SuperLife. 1. Existing UniMed members should complete this section. Enter your existing UniMed number: Please indicate which UniMed medical plan you are currently in: If you wish to change your current UniMed medical plan, please enter the new plan name. You will also need to complete a UniMed form. 2. If you are not an existing UniMed member, you should complete this section, plus a UniMed form. (please tick the medical plan you are applying for): UniCare Plus Major Surgical + GP Major Surgical base plan Major Surgical + GP + dental 100 Major Surgical + specialists Major Surgical + GP + dental 400 Major Surgical + specialists + dental 100 Major Surgical + GP + specialists Major Surgical + specialists + dental 400 Major Surgical + GP + specialists + dental 100 Major Surgical + GP + specialists + dental Excess (Note: applies to Major Surgical plans only). In respect of a hospital/surgical claim, I want an excess for each claim of: No excess I will meet the first $500 dollars. A discount to the premium applies if you choose the $500 excess. 4. List dependants - list all family members to be covered by your medical plan, including you. Name Sex (tick one) Male Female Date of birth (dd/mm/ccyy) E. Signature I apply for the above insurances as identified. Signature Date: (dd/mm/ccyy) superlife@superlife.co.nz Charlotte Street, Eden Terrace, Auckland 1021 PO Box 8811, Symonds Street, Auckland