Employer Insurance Application

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1 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 (PDS) which is a summary of important information relating to Property Focused Super. The details in the PDS will help you to understand the product and decide if it is appropriate to your needs. Please complete forms in BLOCK LETTERS, using BLACK or BLUE pen only. This application will be invalid unless it is signed. Return completed forms by mail to Property Focused Super, PO Box 1282, Albury NSW INSURANCE BENEFITS DEATH & TOTAL AND PERMANENT DISABLEMENT (TPD) INSURANCE I/We would like to offer Employer Group Insurance cover for Death or Death & TPD to our member employees (please tick yes or no): Yes No If yes, please complete a and b below: a. the TYPE OF COVER you would like to offer AND b. the LEVEL OF COVER you would like to offer (please tick one): (please nominate one benefit type only): Death Only OR Death & TPD Future Service Formula % Salary Future Service OR Multiple of Salary Benefit OR Units of Basic Cover Salary units OR Set Scale of Cover (please attach separate details) OR Fixed Dollar Amount $ OR Other Tailored Benefit Design (please attach separate details) SALARY CONTINUANCE INSURANCE (SCI) I/We would like to offer Employer Group Insurance cover for Salary Continuance to our member employees (please tick yes or no): Yes No If yes, please complete a, b, c and d below: a. the WAITING PERIOD to apply (ie. period employee will be off work before Salary Continuance benefits may commence) (please tick one): 30 days 60 days 90 days b. the BENEFIT PERIOD to apply (ie. maximum period during which your employee will receive Salary Continuance benefits) (please tick one): c. the PERCENTAGE OF INCOME to apply (ie. the monthly amount your employee will receive) (please complete): 2 years 5 years (Maximum 75% of salary) % d. the PERCENTAGE OF INCOME for superannuation contribution protection (ie. paid as contributions to the employee s Plan account) (please complete): (Maximum 10% of salary) % OFFICE USE ONLY 27

2 for Property Focused Employer Sponsored Super (page 2 of 5) 2 NEW MEMBERS DETAILS Complete this Form to add new members to your Property Focused Employer Sponsored Super plan. If you are providing information for more than five members, please photocopy this form. PROPERTY FOCUS EMPLOYER SPONSORED SUPER NUMBER (if known) MEMBER 1 Title Mr Mrs Miss Ms Other 28

3 for Property Focused Employer Sponsored Super (page 3 of 5) MEMBER 2 Title Mr Mrs Miss Ms Other MEMBER 3 Title Mr Mrs Miss Ms Other 29

4 for Property Focused Employer Sponsored Super (page 4 of 5) MEMBER 4 Title Mr Mrs Miss Ms Other Surname Given name/s Male Female Date of Birth (DD/MM/YYYY) Residential Address MEMBER 5 Title Mr Mrs Miss Ms Other Surname Given name/s Male Female Date of Birth (DD/MM/YYYY) Residential Address 30

5 for Property Focused Employer Sponsored Super (page 5 of 5) 3 EMPLOYEES ABSENT FROM WORK Please complete this section to list those employees who were NOT At Work on the date they joined your Property Focused Employer Sponsored Super plan. Employee Name Reason for Absence from Work Date Expected to Return to Work 4 EMPLOYER DECLARATION I/We hereby certify that: Listed in section 2 are those employees who have joined your Property Focused Employer Sponsored Super plan within 120 days of first becoming eligible (usually the date they started employment with their participating employer), and were actively At Work on the day they joined. At Work means: you are actively at work and competently performing all the essential duties of your usual occupation without restriction, or are on approved leave other than leave which are taken for reasons related to Injury or Illness; and who are not receiving or claiming and/or entitled to claim income support benefits from any source including workers compensation benefits, statutory transport accident benefits and disability income benefits. Listed in Section 3 are those employees who were NOT At Work on the day they joined or did not join your PropertyFocused Employer Sponsored Super plan within 120 days of becoming employed with the company. I/We understand that: Those employees listed in Section 3 will not normally be entitled to automatic insurance cover through the Property Focused Employer Sponsored Super plan, and as such, may need to have medical evidence assessed and accepted by the Insurer before any insurance cover can be granted. In the event of a claim, Hannover will require proof and will independently assess whether on the date of joining the plan the member has met the full At Work requirement. Failure to provide a member s At Work status may result in their insurance benefits being voided by the Insurer. Providing false or misleading information may also result in the member s insurance benefits being voided by the Insurer. Employer Signature Date (DD/MM/YYYY) Name Position For assistance, please visit or contact your licensed financial adviser or the Client Service Line on

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