Member Details form. Member Application Form. Step 1 Your details. Complete this form to become a member of LUCRF Super.

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1 Member Details form Member Application Form w Complete this form to become a member of LUCRF Super. Please complete all relevant sections using CAPITAL LETTERS and a BLACK or BLUE pen. Step 1 Your details You have an employer who will be contributing to this account. Complete all steps except 10. (You will be automatically provided with our default insurance and have the opportunity to increase your cover to our Automatic Acceptance Levels). You are self-employed or do not have an employer contributing to this account. (You are known as a Personal Plan member). Complete all steps except 5, 6 & 7. (If you wish to apply for insurance, you will need to complete our Member Insurance Election Form). Date of birth (dd/mm/yyyy) / / Please cross [ ] the appropriate box: Mr Mrs Miss Ms Other (please specify) First name(s) Residential/Street address (compulsory) Unit/Street number Street name Suburb/City/Town State/Territory Postcode Postal address if different to residential Unit/Street/PO Box number Street name Suburb/City/Town State/Territory Postcode Please send all correspondence to (please cross [ ]): Residential address Postal address Contact details Mobile Work Home address Please read our Personal Information Collection Statement at lucrf.com.au/privacy Issued 1 July 2014 by L.U.C.R.F Pty Ltd ABN AFSL as Trustee for Labour Union Co-operative Retirement Fund ABN (LUCRF Super). LUCRF0526_0714 Member Application Form Page 1 of 8

2 Step 2 Tax file number (TFN) The Fund is authorised to seek your TFN under the Superannuation Industry (Supervision) Act We will use your TFN to verify your identity with the Australian Tax Office. This will be done in confidence and only for legal purposes, which may change in the future. You do not have to provide your TFN, but if you don t, we will not be able to accept after-tax contributions from you and will have to deduct tax at the highest marginal rate plus the Medicare Levy. Please refer to our Super Member Guide (Product Disclosure Statement) for further information, available at lucrf.com.au or call I advise that my TFN is: Step 3 Your beneficiary details When you open a LUCRF Super account, it is important that you carefully consider who you wish to receive your superannuation benefit in the event of your death. Option 1 Pay benefit to my estate/legal personal representative/executor Alternatively, LUCRF Super offers non-binding or binding nominations. To make a non-binding nomination please complete the relevant details in option 2 below. To make a binding nomination in option 3 below, you will need to complete a Binding Death Benefit Nomination Form. Option 2 Non-binding nomination This type of nomination is used as a guide for the Trustee when deciding how your death benefit (super and any insurance amount) will be distributed. To advise the Trustee of your preferred nomination, please list your beneficiaries below. First name and initial (e.g. John D) Relationship to you % share First name and initial (e.g. John D) Relationship to you % share First name and initial (e.g. John D) Relationship to you % share First name and initial (e.g. John D) Relationship to you % share MUST TOTAL 100% If you would like to nominate more beneficiaries, attach your own list to this form, or call a LUCRF Representative on to obtain a Change of Details Form. Option 3 Binding nomination This type of nomination means the Trustee must pay your death benefit to the person(s) you have nominated (subject to superannuation law). Binding nominations are valid for three years and you will need to confirm your nomination within this period for it to remain valid. You can change or cancel your nomination at any time. Important: If you would like to choose this option, you must complete a Binding Death Benefit Nomination Form available by calling us on , or by visiting lucrf.com.au Member Application Form Page 2 of 8

3 Step 4 Super Search consent You can authorise LUCRF Super to use your Tax File Number (TFN) (if provided) to search and act on your behalf to consolidate your super. Please cross [ ] below to provide consent. I hereby consent for LUCRF Super to act on my behalf and use my Tax File Number (TFN) for superannuation purposes. I consent for my TFN to be used to seek superannuation information using the ATO facility and contacting other superannuation entities or RSA providers for information relating to myself. This consent will remain in place until cancelled by you. LUCRF Super will only use your TFN in accordance with your consent. Insurance Your default cover When you first join LUCRF Super and you have an employer who pays super contributions into your account, you are automatically allocated the following insurance (this is known as your default cover): Up to 69 years of age 1 unit of Standard Fixed Premium Death and Total & Permanent Disablement (TPD) cover ($3.00 per week * ) Aged 70 and over No insurance. * Cost of insurance is deducted directly from your super account Note: If you are a Personal Plan member (self-employed or do not have an employer contributing to this account) you are able to apply for cover by completing our Member Insurance Election Form and a OnePath Personal Statement. Insurance eligibility is at the discretion of the insurer. To learn more, please read our Super Member Guide available from lucrf.com.au or by calling us on Insurance Your options LUCRF Super offers a range of insurance options that gives you the flexibility to tailor insurance cover to best suit your personal circumstances. Your insurance options are: LUCRF Super insurance options Products Types of cover Work categories Death & TPD Provides a benefit to you if you become totally and permanently disabled (upon acceptance) or to your dependants, nominated beneficiaries or legal personal representative (your estate) in the event of your death. Death Only Provides a benefit to your dependants, nominated beneficiaries, or your legal personal representative (your estate) in the event of your death (upon acceptance). Income Protection Provides you with temporary financial support if you are unable to work through illness, injury or accident (upon acceptance). Fixed Premium or Fixed Amount Fixed Premium or Fixed Amount Fixed Amount 30, 60 or 90 Day waiting period Standard, White Collar or Professional Standard, White Collar or Professional Light Blue Heavy Blue, White Collar or Professional Changing your default cover Within 90 days of joining Providing you have a contributing employer, within 90 days from the date of your welcome letter you can automatically obtain additional cover of: A maximum of 6 units of Fixed Premium death insurance * A maximum of 4 units of Fixed Premium TPD insurance * This can be through a combination of Death & TPD and/or Death Only cover. You can also convert the Fixed Premium cover into the equivalent value of Fixed Amount cover. You can also apply for up to $700 a week Income Protection cover by answering one simple question. Income Protection cover is for new events only and you must be either a full-time or permanent part-time employee working more than 15 hours per week. To change your default cover within these levels, please complete Step 5 of this form. If you would like to apply for insurance above these levels, you must complete a Member Insurance Election Form and/or a Member Income Protection Form and if required a OnePath Personal Statement. * Any cover in excess of $1.1million will require completion of a OnePath Personal Statement. After 90 days of joining If you want to change your cover after 90 days of your welcome letter, you will need to complete a Member Insurance Election Form and/or the Member Income Protection Form and if required a OnePath Personal Statement. Member Application Form Page 3 of 8

4 Types of Death & TPD cover Fixed Premium (default) This is where the premium (cost) of your insurance is set at a fixed cost per unit. Whilst the premium remains the same, the total insured amount will reduce as you age. Fixed Amount This type of cover provides a specific dollar amount of insurance. Whilst the amount of cover is fixed and does not change, the premium you pay will increase as you age. Work categories for Death & TPD To reflect the various risks associated with the different jobs people do, there are three work categories for Death and TPD or Death Only insurance; Standard, White Collar and Professional. Standard (default) For members whose work includes some degree of manual labour usually conducted outside an office environment. White Collar Where the duties of your occupation are limited to professional, administrative, clerical, secretarial, or similar deskbound (sedentary) tasks that do not involve manual work and are undertaken entirely (or at least 80%) within an office environment. Professional To be eligible for Professional insurance cover, you will need to meet the following criteria: Your current annual salary package (including superannuation guarantee contributions) is in excess of $150,000 per annum and you spend at least 80% of your time in an office environment. You are also: A professional white-collar worker with a university degree qualification relevant to the field of your main occupation OR An executive or senior managerial white-collar worker and not self employed. Work categories for Income Protection The cost of Income Protection insurance will depend on the type of work you do, called your work category. There are four work categories described below: Professional To be eligible for Professional insurance cover, you will need to meet the following criteria: Your current annual salary package (including superannuation guarantee contributions) is at least $150,000 per annum and you spend at least 80% of your time in an office environment and either: You are also: You are a professional white collar worker with a university degree qualification relevant to the field of your main occupation. OR You are an executive or senior managerial white-collar worker and not self-employed. White Collar For professional, clerical and administrative white collar workers who do not perform any manual work, as well as sales people not involved in deliveries. Light Blue For skilled and unskilled workers, performing light manual work and involved in non-hazardous industries and/or tasks. Light Blue also covers supervisors of Heavy Blue workers or fully qualified tradespeople (details of qualifications must be provided) Heavy Blue For skilled or semi-skilled manual workers and heavy machine operators who are not exposed to high risk accidents, health hazards or who do not participate in high risk occupations are classified Heavy Blue. Note: In the event of a claim, the insurer will assess your details including whether you have fully disclosed all relevant information. Insurance eligibility is at the discretion of the insurer. Case study one Alex Alex is a storeman, aged 35. He wants to get as much Death and TPD insurance as he can. He has decided to have the following combination of Fixed Premium and Fixed Amount cover: Fixed Amount cover to the equivalent dollar value of 4 units of Death and TPD Fixed Premium (the maximum TPD cover you can get), providing him with $425,000 of cover (rounded to the nearest $1,000) 2 units of Fixed Premium Death Only cover at $136,000 So Alex now has total cover of Death $561,000 and TPD $425,000. Case study two Michaela Michaela is a payroll manager who is 52 years old. She wants to have as much death cover as possible, but also wants some TPD cover. She chooses the following combination of Fixed Premium and Fixed Amount cover: Fixed Amount cover to the equivalent dollar value of 4 units of Fixed Premium Death Only cover providing $193,000 (rounded to the nearest $1,000) 2 units of Fixed Premium Death and TPD cover providing $54,220 of cover $700 per week Income Protection cover So Michaela now has total cover of Death $247,220 and TPD $54,220. When applying for the insurance, Michaela makes sure she answers the work category questions to change her work category to white collar. Member Application Form Page 4 of 8

5 Fixed Premium The table below shows the amount and cost of Fixed Premium default cover available from LUCRF Super. Age at next birthday Death & TPD $3 per week per unit of cover Fixed Premium Cover Standard White Collar Professional Death Only $1.50 per week per unit of cover Death & TPD $3 per week per unit of cover Death Only $1.50 per week per unit of cover Death & TPD $3 per week per unit of cover Death Only $1.50 per week per unit of cover 16 to 30 $134,730 $90,720 $219,350 $147,720 $253,980 $171, to 35 $132,050 $68,300 $214,900 $111,200 $248,830 $128, to 40 $106,290 $68,300 $173,170 $111,200 $200,500 $128, to 45 $59,180 $51,130 $96,320 $83,340 $111,520 $96, to 50 $29,650 $29,650 $48,230 $48,230 $55,830 $55, to 55 $16,630 $29,650 $27,110 $48,230 $31,380 $55, to 60 $9,790 $29,650 $16,170 $48,230 $18,710 $55, to 65 $8,850 $26,570 $14,500 $43,260 $16,790 $50, to 70 $6,040 * $16,780 $9,550 * $27,990 $11,050 * $32,410 * TPD cover restrictions may apply. Please refer to our Super Member Essentials for further details. Please refer to our Super Member Essentials at lucrf.com.au for all insurance tables. Step 5 Increase your insurance cover (when joining or within 90 days from the date of your welcome letter) If you would like to increase your insurance cover within our Automatic Acceptance Levels, and.or apply for Income Protection insurance, please complete the sections below. Step 5a Your insurance selection Death and TPD insurance I am seeking a total of units of Death & TPD cover OR total Death & TPD (Fixed Amount) cover of $ I am seeking a total of units of Death Only cover OR total Death Only (Fixed Amount) cover of $ Any cover in excess of $1.1million will require completion of a OnePath Personal Statement. Limits apply: Please refer to Changing your default cover section on the page 3 for more information. (must be in multiples of $1,000). Step 5b Your insurance selection Income Protection insurance If you do not currently have Income Protection insurance through LUCRF Super, you can obtain: Total Income Protection insurance of up to $700 per week ($36,400 per year) I am seeking a total of $ per week of Income Protection insurance Select the appropriate waiting period: 30 days 60 days 90 days As at the date of signing this application, I confirm that: 1. I am off work due to injury or illness or restricted from performing any of the usual duties of my occupation due to injury or illness on a full time basis of at least 30 hours per week (even if not currently working on a full-time basis for non-medical reasons) YES NO (Note: You must answer NO to the question to be eligible for the automatic insurance. If you cannot answer NO you can still apply for additional cover by completing the OnePath Personal Statement). Member Application Form Page 5 of 8

6 Step 6 Your work category All members must complete these questions To determine your occupation classification, please answer the following questions: Please cross [ ]: 1. Do you spend at least 80% of your total working time in an office or similar environment performing administrative, clerical or sedentary type duties? YES NO 2. Do you have a university degree qualification relevant to the field of your main occupation or, are you an executive or senior managerial white-collar worker and not self-employed or are you a member of a professional institute? YES NO 3. Is your current annual salary package (including superannuation guarantee contribution) in excess of $150,000? YES NO If you answer no to all 3 questions, you fall within the Standard insurance category (for Death & TPD insurance) If you answer yes to questions 1 or 1 & 2 you fall within the White Collar insurance category If you answer yes to all 3 questions, you fall within the Professional insurance category. Step 6a Your work category Additional questions to be completed for Income Protection insurance Only complete questions 4 & 5 if you answered NO to questions 1, 2 & Do you have a recognised trade qualification relating to your occupation or, does your occupation require you to perform light manual work or, are you a supervisor of blue collar workers and your duties include up to 10% of light manual work? (e.g. an electrician, mechanic, printer, signwriter, greengrocer, carpenter, storeman, poultry processing employee, plumber etc? YES NO 5. Are you a skilled or semi-skilled worker whose duties include heavy manual work or are you required to operate heavy machinery (e.g. qualified wall/floor tiler, glazier, bulldozer driver, forklift driver)? YES NO If you answer no to questions 1 and 5 and yes to question 4, you will be classified as Light Blue (for Income Protection insurance). If you answer no to questions 1 and 4 and yes to question 5, you will be classified as Heavy Blue (for Income Protection insurance). If you answer no to questions 1, 4 and 5, income protection cover will be declined. Step 7 Your employer s details Employer name Employer contact/representative Title Dated joined employer (dd/mm/yyyy) / / Employer phone number Employer site/location (if applicable) Workplace address Unit/Street number Street name Suburb/City/Town State/Territory Postcode What is your main occupation? If yes, please specify your occupation(s) Are you engaged in any other occupations? YES NO Member Application Form Page 6 of 8

7 Member investment choice When you join LUCRF Super your account is automatically invested in the MySuper Balanced (default) investment option. This option has a diversified mixture of growth assets such as shares and property, and defensive assets like cash and fixed interest. If you want your super invested differently to the default option, you will need to complete a Member Investment Choice Form. There is a choice of ten investment options that are Pre-mixed or Asset Class (see table below). You can choose one option or a mix of options. Pre-mixed investment options Each option is made up of a blend of growth and defensive asset classes (diversified) MySuper Balanced (default) Conservative Moderate Targeted Return High Growth Asset Class investment options Each option invests solely in a particular asset class Cash Indexed Shares Australian Shares International Shares Property Step 8 Your communication choices We will send your annual statement and other important information as required by legislation, however if you do not wish to receive additional information, please indicate this below (you can alter your preference at any time by contacting us). I do not wish to receive additional information from LUCRF Super Step 9 Sign and date this form Duty of disclosure 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. Your duty, however, does not require disclosure of a matter: That diminishes the risk to be undertaken by the Insurer That is common knowledge That your Insurer knows or, in the ordinary course of his/her business, ought to know As to which compliance with your duty of disclosure is waived by the Insurer. Non-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 void the contract within 3 years of having entered into it. If your non-disclosure is fraudulent, the Insurer may void the contract at any time. An Insurer who is entitled to void a contract of life insurance may, within 3 years of entering into it, elect not to void it but to reduce the sum 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. I declare that: I understand my duty of disclosure and the effect of non-disclosure under the Insurance Contracts Act I have answered all questions in this application truthfully and correctly (to the best of my knowledge), and have disclosed everything I know that could affect OnePath Life s decision to accept my application. I understand that I must advise OnePath Life of any changes in my health from now until I am notified in writing that my application has been accepted. I understand that insurance cover through LUCRF Super will be provided to me on the terms contained in LUCRF s insurance policy as changed from time to time. I have read and understood the Super Member Guide (Product Disclosure Statement) and the associated reference material as currently available at lucrf.com.au/forms-and-publications I consent to the collection, use and disclosure of my personal information in accordance with the OnePath Life Privacy Statement, available at onepath.com.au/privacy-policy or by calling , and the LUCRF Super Personal Information Collection Statement and Privacy Policy available at lucrf.com.au/privacy or by calling I understand that if my application is accepted I will be notified in writing and my insurance cover will change in accordance with the direction I have made in this form. The change will be effective from the date LUCRF s insurer accepts this application and provided my member account has adequate funds to meet the premium payable. Member signature 7 Date (dd/mm/yyyy) / / Member Application Form Page 7 of 8

8 Step 10 Proof of identification (Personal Plan members only) When you open a LUCRF Super Personal Plan account, you will need to provide a certified copy of proof of identification. The following are legally accepted documents: EITHER ONE of these documents only: Driver s licence issued under State or Territory law Passport OR One of the documents in Section 1, and one of the documents in Section 2: Section 1 Birth certificate or birth extract Citizenship certificate issued by the Commonwealth Pension card issued by Centrelink that entitles the person to financial benefits AND Section 2 A letter from Centrelink regarding a Government assistance payment notice issued by Commonwealth, State or Territory Government or local Council within the past 12 months that contains your name and residential address. For example: Tax Office Notice of Assessment Rates notice from local Council Certification of personal documents All copied pages of ORIGINAL proof of identification (including all linking documents) need to be certified as true copies of the original document by a person authorised to do so. The person who is authorised to certify the documents must sight the original and the copy and make sure that both documents are identical. They then must ensure that all pages are certified as true copies by writing or stamping certified true copy followed by their signature, printed name, qualifications and the date. In accordance with Anti-Money Laundering and Counter-Terrorism Financing Rules Instrument 2007 (No.1), persons who can certify copies of the originals as true and correct for these purposes include: A Pharmacist A registered Medical Practitioner A Police officer A permanent employee of Australia Post with two or more years continuous service An officer with, or authorised representative of, a holder of an Australian Financial Services Licence (AFSL), having two or more years of continuous service. This is a true and correct copy of the original document Name:... Qualification:... (e.g. Pharmacist, Police Officer etc) Registration number:... EXAMPLE Signature:... Date:... Checklist Before you send the form to us, make sure you have: 3 3 Completed all relevant steps Signed and dated this form Send this form to: LUCRF Super PO Box 211 North Melbourne VIC 3051 F E If you need any help completing this form, please call us on or Member Application Form Page 8 of 8

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