Insurance Request Form

Transcription

1 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 LETTERS. This form is applicable to more than one product. Please select the one that applies to you: Russell SuperSolution Master Trust Russell iq Super. 1. Personal details We will use these details to calculate your benefits and to communicate with you about your super. If your details change, please advise us by calling the Helpline or visiting a. Title (please select) Mr Mrs Miss Ms Dr Other b. Surname c. First name(s) d. Date of birth (DD MM YYYY) e. Sex (please select) f. Member/Investor number Male Female g. Address State Postcode h. Work telephone i. Home telephone j. Mobile telephone* k. * l. Secondary * * By providing your address and/or mobile telephone, you are confirming that you would like to receive future communications electronically or by SMS. This includes news and updates about superannuation, as well as links to online information, for example personal information in the online login area. IN PREPARING THIS FORM THE TRUSTEE HAS NOT TAKEN INTO ACCOUNT THE INVESTMENT OBJECTIVES, FINANCIAL SITUATION AND PARTICULAR NEEDS (FINANCIAL CIRCUMSTANCES) OF ANY PERSON. ACCORDINGLY, BEFORE ACTING ON ANY ADVICE, YOU SHOULD ASSESS WHETHER THE ADVICE IS APPROPRIATE IN LIGHT OF YOUR OWN FINANCIAL CIRCUMSTANCES. TOTAL RISK MANAGEMENT PTY LIMITED ABN , AFSL NO , TRUSTEE OF THE RUSSELL SUPERSOLUTION MASTER TRUST ABN SS_F_PRI_GDIV_InsReq_V1F_1502 PAGE 1 OF 11

2 2. Insurance cover Death Only, and Death and Total and Permanent Disablement (TPD) cover Please enter your required insurance details below. te: If you apply for insurance, you must also complete the TAL Personal Statement and the Consent Form attached. Your insurance cover can be either fixed dollars or units. It cannot be a combination of both. Request new cover I want to purchase Death Only cover of units OR Fixed cover (multiples of $1,000) $ I want to purchase combined Death and TPD cover of units OR Fixed cover (multiples of $1,000) $ Request a change in cover (Cancel/Increase/Decrease) I no longer want Death only or Death and TPD insurance cover. I want to fix all of my insurance cover, so the value doesn t reduce overtime. [Please refer to the Product Disclosure Statement (PDS) to check how this may affect your insurance fees.] I want to change my level of insurance cover. te: If you request to increase your insurance, you must also complete the TAL Personal Statement and the Consent form attached. Death Only cover Please refer to the PDS for the value and cost per unit. Current insurance cover* New insurance cover (total number of units required in whole numbers only) $.00 units OR Fixed cover (multiples of $1,000) $.00 Death and TPD cover Please refer to the PDS for the value and cost per unit. Current insurance cover* New insurance cover (total number of units required in whole numbers only) $.00 units OR Fixed cover (multiples of $1,000) $.00 * As shown on the last statement or letter you received from the Fund or in your online account. Income Protection cover Income Protection cover is 75% of your annual salary, where salary is defined as Ordinary Time Earnings. te: You may be required to provide proof of your current salary. I want to purchase Income Protection cover*. My annual salary is $.00 I no longer want Income Protection cover. * As shown on the last statement or letter you received from the Fund or in your online account. PAGE 2 OF 11

3 3. Occupation Category This section is optional If you would like to change your Occupation Category, please complete the questions below. You are not required to complete the Personal Statement or privacy consent attached, but you need to sign and date this form. The insurance benefits in the Russell iq Super or General Division depend on Occupation Categories. This means that you are charged insurance fees based on the risk profile of your occupation. The plan s default category is Standard. If you are classified as Low Risk or Professional, you can save money on insurance fees. Occupation Categories for Russell SuperSolution Professional White Collar Professionals performing no manual duties (e.g. lawyer, accountant). Usually those with a tertiary qualification or registration by a professional body (they must be using these qualifications in their occupation). Those well established senior executives (with 10 or more years in that role) with incomes in excess of $80,000 pa, without tertiary qualifications may also be included. Low Risk Clerical, administration and managerial occupations involving office and travel duties. manual work (e.g. administrator, book-keeper, computer operator). Includes occupations with tertiary qualifications that involve very light physical work (e.g. osteopath, physiotherapist). Certain qualified tradespeople (e.g. electrician) who engage in light manual work only. Includes business owners in non-hazardous industries involved in light manual work (e.g. coffee shop owner) and those who may supervise medium blue collar workers (no more than 25% of their work time). Includes occupations that are not limited to an office, where travel is an essential part of the job (e.g. field surveyor). Standard Qualified skilled tradespeople in non-hazardous industries wholly involved in manual duties (e.g. carpenter, plumber, plasterer, mechanic). Heavy manual workers in non-hazardous industry performing higher risk occupations (e.g. interstate bus driver, warehouse worker, labourer, bricklayer, house removalist). 1. Are the duties of your occupation limited to professional, administrative, clerical, secretarial or similar white collar tasks that do not involve manual work and are conducted entirely (or at least 80%) within an office environment (excluding travel from one office environment to another)? 2. Are you earning more than $80,000 each year from your profession? 3. Do you have a tertiary qualification, or are you a member of a professional institute or registered by a government body? 4. Are you in a management role? 5. If you cannot answer YES to question (1), but believe you may qualify for a Low Risk or Professional occupational category due to your occupation and/or due to the minimal time you perform your duties outside an office environment, please provide details of your occupation and a brief description of your duties below. PAGE 3 OF 11

4 4. Duty of disclosure Before you enter into or become insured under a contract of life insurance with an insurer, you have a duty under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, that is relevant to the insurer s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you extend, vary or reinstate your insurance. Your duty, however, does not require disclosure of a matter:» that diminishes the risk to be undertaken by the insurer;» that is of common knowledge;» that your insurer knows or, in the ordinary course of its business, ought to know; or» as to which compliance with your duty is waived by the insurer. n-disclosure If you fail to comply with your Duty of Disclosure and the insurer would not have covered you on any terms if the failure had not occurred, the insurer may avoid the cover within three years of issuing it. If your non-disclosure is fraudulent, the insurer may avoid your cover at any time. An insurer who is entitled to avoid your cover may, within three years of issuing it, elect not to avoid it but to reduce the sum that you have been insured for in accordance with a formula that takes into account the insurance fee that would have been payable if you had disclosed all relevant matters to the insurer. 5. Declaration and signature I declare that» All answers provided by me on this form are true and correct.» I have read and understand the Duty of Disclosure and I am aware of the consequences of non-disclosure. I understand that the Duty of Disclosure continues after I have completed this statement until my application for cover has been accepted in writing by Russell SuperSolution and the Insurer.» I have not withheld any information that may affect the Insurer s decision as to whether to accept my application to change my occupation category.» I am currently employed and am able to carry out all of the identifiable duties of my employment without restriction due to injury or illness, on a full-time basis. Furthermore» I understand any reduction in cover will be processed as soon as practicable after this form is received by Russell SuperSolution.» I understand the provision of insurance cover is subject to acceptance by the Insurer.» I understand insurance fees, where applicable, will be deducted from my Russell SuperSolution Master Trust account or my Russell iq Super account (whichever is applicable).» I acknowledge that if I do not complete this application correctly, or I do not sign and date this form, my previous occupation category will remain in force.» I acknowledge that insurance cover will only be provided on the terms and conditions set out in the contract of insurance with Russell SuperSolution s Insurer and as agreed between Russell SuperSolution and its Insurer from time to time.» I understand that the occupation category will be updated from date of acceptance from the Insurer/Fund and the adjusted insurance fee will apply from this date onwards, and will not be backdated. For information on the Insurer s privacy and information handling practices, read their Privacy Policy Statement at or call for a copy. Member/Investor signature Date (DD MM YYYY) Member/Investor name Please return this form to the address for your product. Russell SuperSolution Locked Bag A4094 Sydney South NSW 1235 Russell iq Super Locked Bag A4094 Sydney South NSW yoursupersolution@russellsuper.com russelliq@russell.com PAGE 4 OF 11

5 Member s Personal Statement Policy number Member number Plan administrator YOUR DUTY OF DISCLOSURE Before you enter into a contract of life insurance with an insurer, you have a duty under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer 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 us before you extend, vary or reinstate a contract of life insurance. Your duty however, does not require disclosure of a matter: that diminishes the risk to be undertaken by the insurer; that is of common knowledge; that your insurer knows or, in the ordinary course of his business, ought to know; disclosure of which is waived by the insurer. The duty of disclosure applies even after this Application is completed until TAL advises acceptance of insurance. n-disclosure If you fail to comply with your duty of disclosure and the insurer would not have entered into the contract on any terms if the failure had not occurred, the insurer may avoid the contract within three years of entering into it. If your non-disclosure is fraudulent, the insurer may avoid the contract at any time. An insurer who is entitled to avoid a contract of life insurance may, within three years of entering into it, elect not to avoid it but to reduce the sum that you have been insured for in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to the insurer. All questions on this Personal Statement are relevant as to whether or not TAL accepts the risk and, if so, on what terms. Consequently, all questions must be answered correctly and completely. Block letters should be used. A dot or dash is not acceptable. 1. PERSONAL DETAILS (please print answers clearly) Name of plan Policy number Title Mr Mrs Miss Ms Other Surname Given name Date of birth / / (DD/MM/YYYY) Gender M F May TAL contact you directly to clarify or gather information in relation to this application? If yes, preferred method of contact: Phone Contact time address Phone. ( ) TAL Life Limited ABN AFSL TALG TAL MPS MEMBER S Member s PERSONAL Personal STATEMENT Statement 1 of 6 1

6 2. OCCUPATION DETAILS 1. Self employed Employee full-time OR Part-time hours p/week weeks p/year 2. Your occupation Industry 3. Duties performed 4. Annual salary (includes packaged items but excludes bonuses/commission) $ 3. INSURANCE APPLICATION Death sum insured $ B period TPD sum insured Waiting period 1. Is this an increase? 2. Have you ever held or applied for any life, disability, accident & sickness or trauma insurance, that was declined, 3. Compensation or Motor Vehicle Third Party? 4. Do you have, or are you applying for, any other life or disability cover? If yes to 2, 3 and or 4, please provide full details below. Name of company Cover type Sum insured Date of application Accepted Loaded Exclusion Declined To be replaced? $ / / $ / / $ / / 4. HABITS AND ACTIVITIES 1. Do you drink alcohol? If yes, state type and daily quantity. 2. Have you smoked in the past 12 months? If yes, state form and daily quantity. 3. Have you ever used or injected yourself with any drug not prescribed by a doctor, or received counselling or treatment for the use of alcohol or drugs? If yes, complete a drug use or alcohol consumption questionnaire. 4. Do you currently, or do you intend to engage in any hazardous pastime and/or sporting activity such as aviation (other than as a fare paying passenger travelling over recognised routes), motor racing, diving, football, parachuting, hang-gliding or any other extreme sport? If yes, please complete a sports and pastimes statement. 5. Do you intend travelling outside Australia within the next two years? If yes, please provide details below (where, when, duration and reason). MEMBER S Member s PERSONAL Personal STATEMENT Statement 2 of 26

7 6. Are you an Australian or New Zealand citizen? 7. Do you hold an Australian Permanent Resident s Visa? If no to 6 and 7, please provide details. 5. PERSONAL STATEMENT 1. Please state your: Height (cm) 2. Name and address of your usual doctor or medical centre Surname Weight (kg) Given name Address State Postcode 3. Details of last medical consultation with your usual doctor or medical centre Date / / (DD/MM/YYYY) Reason Outcome/results 4. If you have attended that doctor for less than 12 months, name and address of previous doctor Surname Given name Address State Postcode 5. A. Within the LAST THREE YEARS have you consulted, been examined, treated by, or received advice from any doctor, psychologist, psychiatrist, counsellor, chiropractor, physiotherapist or any other health care professional (naturopath, etc) or been in a hospital or been advised to have an operation or taken any medication, drugs, stimulants, sedatives or tranquilisers? B. Have you EVER had an ECG, X-ray, transfusion, mammogram, surgery or any other investigation? C. Have you EVER had any blood tests which revealed an abnormality e.g. raised blood sugar, liver function, renal function results, or anaemia, etc? D. Do you contemplate seeking any medical examination, advice, treatment or surgery, in the future? Please provide full details for all answers. Question Dates (from /to) Name / Address of doctor, hospital or clinic Condition, medications, Recovery % MEMBER S Member s PERSONAL Personal STATEMENT Statement 3 of 6 3

8 6. PERSONAL STATEMENT ENERAL MEDICAL QUESTIONS Please provide details for all answers in General Medical Questionnaire at Section Have you ever had, been advised that you had, or received advice or treatment for any of the following: A. High blood pressure, raised cholesterol, chest pain, heart attack, rheumatic fever, stroke or circulatory disorder? B. Bowel, stomach or intestinal problem, gall bladder or liver disease? C. Epilepsy, stroke, paralysis, multiple sclerosis, fainting attacks? D. Depression, anxiety, panic attacks, stress, chronic fatigue or any mental or nervous condition? E. Diabetes, sugar in urine, pancreatic or thyroid problem? F. Cancer, tumour, melanoma, sunspots, mole or growth of any kind? G. Disease, injury or disorder of joints, neck, back or bones, gout, arthritis or a repetitive strain injury or tendonitis? H. Impairment of sight, hearing or speech? I. Asthma, bronchitis, or any lung complaint? J. Leukaemia, haemochromatosis, or any blood problems? K. Kidney, or bladder problems? L. Psoriasis, eczema, or any skin problem? M. Any other disability, congenital abnormality, deformity or symptoms of ill health, illness or injury? N. Has the virus which causes AIDS antibodies to that virus? O. Have you ever engaged in any activity/ies reasonably accepted to having an increased risk of exposure to the HIV/AIDS virus? Females only P. Have you ever had any gynaecological conditions (e.g. endometriosis, abnormal Pap smear, etc)? Q. Have you ever had any complications of pregnancy or childbirth? R. Are you currently pregnant? If yes, what is the expected delivery date? / / S. Have you ever had a breast lump (even if you have not seen a doctor about it)? 2. Family History disease, high blood pressure, mental problems or breakdown, haemophilia, Huntington s Chorea or any hereditary disease? 3. Please give details of your family medical history. Relative Living relatives Deceased relatives Current age Specify current state of health Age at death Specify cause of death Mother Father Sisters Brothers MEMBER S Member s PERSONAL Personal STATEMENT Statement 4 of 46

9 7. GENERAL MEDICAL QUESTIONNAIRE Please provide details for all answers in Section 6 A to S. Please complete on a separate sheet if required. Question. Q. Q. Q. Q. A. Date s and description of symptoms. B. What was the condition and which part and side of the body C. What was the medical diagnosis including results of x-rays and investigations? D. What was the frequency (daily, weekly, etc) of attacks or symptoms? E. What was the severity (mild/ moderate/severe) and duration of attacks or symptoms? F. How long were you unable to work or perform your normal duties/activities? G. If a hospital visit was required, please provide date and duration of your stay. H. What advice/treatment did you receive? I. Are you still receiving treatment? If so, please advise nature and frequency of treatment. J. Date treatment/medication ceased. K. any symptoms? L. Degree of recovery (%). M. Please supply the name and address of all doctors, hospitals or other practitioners consulted. MEMBER S Member s PERSONAL Personal STATEMENT Statement 5 of 6 5

10 8. PRIVACY Privacy laws are designed to protect the privacy of individuals. The way in which we collect, use, disclose and handle your information is described in the TAL Privacy Policy available at If you have any questions regarding your privacy or would like to obtain a copy of our Privacy Policy please contact our Privacy O 9. DECLARATION I acknowledge that I have read the notice of my duty of disclosure and understand that this duty also applies until formal I have read and checked any answers not completed in my handwriting and to the best of my knowledge and belief all the answers to the questions in this Application and any supplementary application or personal statement which relate to me are true and correct and no information material to the assessment of this insurance has been withheld. I, the Member, authorise and direct any medical or other practitioner to divulge at any time to TAL Life Limited or to any lawfully constituted tribunal any and all information concerning my state of health and medical history, acquired in the course of professional attendance or consultation. A photocopy of this authority is as valid as the original. T I consent to my personal information (including health and sensitive information) being collected, used or disclosed by TAL Life Limited to its external service providers/contractors as contemplated in this form, including collecting it from or disclosing it to any medical practitioner or third party as required to assess, verify or process my application. This consent applies to any health and sensitive information collected on this form or future forms in relation to this insurance. Full name of Member Signature of Member Date / / 10. MEDICAL AUTHORITY I agree that any medical practitioner or any other person who has been or may hereafter be consulted by me whether named by me or not will be hereby authorised and directed by me to divulge to TAL Life Limited or any legal tribunal all medical or surgical information he/she may have acquired with regard to myself. A as the original. Full name of Member Signature of Member Date / / Please return the completed form to: TAL Life Limited, PO Box 142, Milsons Point NSW Alfred Street South, Milsons Point NSW 2061 T +61 (0) F +61 (0) For enquiries please call E groupriskadmin@tal.com.au MEMBER S Member s PERSONAL Personal STATEMENT Statement 6 of 6

11 Consent Sensitive Information regarding the Underwriting of your Insured Benefits By signing this Form, you consent to the use and disclosure of your personal information to the Trustee, its service providers and other experts and advisers for the following purpose: Assessment by the Fund s insurer of your entitlement to be insured for death and/ or disablement benefits provided by the Fund, relying on input from others, including medical experts. If there is a dispute with respect to your entitlement, the Trustee may be required to disclose this information to a Tribunal or Court. If you do not provide this consent the Insurer may not be in a position to consider whether to provide you with Death and/or Disability Insurance through the Russell SuperSolution Master Trust. If you would like to view a copy of Russell s Privacy Policy or if you have any questions about privacy and Russell please call us on Signature Date / / Name (please print) Please return to: Russell SuperSolution Locked Bag Bag A4094 A4094 Sydney South NSW 1235 Sydney South NSW yoursupersolution@russellsuper.com Russell iq Super Locked Bag A4094 Sydney South NSW russelliq@russell.com SS_F_Per_PerState_V2FF_0909 Member s Personal Statement 7