Transfer of Insurance to SMSF or Investment Platform

Transcription

1 Transfer of Insurance to SMSF or Investment Platform Reference Number (Please ensure the correct quote illustration is attached to this Application Form) Life to be insured name Important Information Before you complete this application form, be aware that TAL or a financial adviser must have provided you with a Product Disclosure ment (PDS) for Accelerated Protection for Investment Platforms dated 12 December The PDS contains important information in relation to Accelerated Protection. Please complete in black ink, using BLOCK letters. Use X in boxes. Use this Transfer of Insurance to SMSF or Investment Platform form to transfer cover to Accelerated Protection where the new policy owner is a Self-Managed Superannuation Fund or a Platform Superannuation Fund and the existing policy being replaced: was underwritten within the last five years; is a group insurance policy or a retail insurance policy funded via an investment platform, masterfund, wrap account or similar; and meets the eligibility criteria outlined in the table below. Term TPD Critical Illness Maximum Entry Age 60nb 60nb 60nb Maximum Sum Insured $3,000,000 $2,000,000 $1,500,000 Maximum sub-standard terms considered* 100% loading To age 55nb: 100% loading Age 56 to 60nb: standard rates only To age 55nb: 100% loading Age 56 to 60nb: standard rates only * For medical sub-standard terms, in addition to the medical loading, we will consider additional loadings/exclusions for non-medical risks. A medical exclusion equates to +50% loading. In addition to this application form, we also require evidence of the existing cover to be replaced as follows: copy of the Policy Schedule ; and copy of the letter of acceptance for the existing cover or any other evidence that illustrates the cover was underwritten; and copy of the latest renewal notice showing that the cover is in force and the current benefits; or the Certificate of Currency from the current insurer Duty Of Disclosure For the purposes of this Duty of Disclosure section, You includes both the Policy Owner and the Life Insured. Before you enter into or become insured under a contract of insurance with TAL Life Limited (ABN ) (TAL) you have a duty under the Insurance Contracts Act 1984 to inform TAL of every matter that you know, or could reasonably be expected to know, is relevant to TAL s decision whether to accept the risk of insurance and issue a policy, and if so, on what terms. You have the same duty to disclose those matters to TAL before you apply to extend, vary or reinstate a policy. Your duty however does not require disclosure of a matter that reduces TAL s risk, is common knowledge, that TAL knows or ought to know in the ordinary course of business, or that TAL tells you it does not need to know. Your duty of disclosure applies even after this application is completed and until TAL advises acceptance of your application and issues a Policy Schedule. If you fail to comply with your duty of disclosure or make a misrepresentation and TAL would not have entered into all or part of the policy on the same terms had TAL known about those matters, TAL may avoid all or part of the policy within three years of entering into it. If your non-disclosure or misrepresentation is fraudulent and TAL would not have entered into the policy on the same terms had it known about those matters, TAL may avoid all or part of the policy at any time. Alternatively, instead of avoiding the policy TAL may decide: (a) to reduce the benefits for all or part of the policy in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to us, although any reduction to benefits payable in respect of the death of a Life Insured can only occur within three years of the commencement date; or (b) for any benefits provided under the policy other than benefits payable in respect of the death of a Life Insured, to vary the policy in such a way as to place you in the position you would have been in if you had disclosed all relevant matters to us. TAL Life Limited ABN AFSL TALR0992/1114 Transfer of Insurance to SMSF or Investment Platform page 1 of 9

2 Existing Insurance Details Is the existing policy a group or retail policy? Group Retail Was the existing policy underwritten in the last five years? Yes No Existing insurer Existing policy number If a retail policy, what was the premium funding source? Existing fund number (if applicable) Was the existing policy modified or offered on non-standard terms including a loading or exclusion? Yes No 1. Personal Details Title First name Middle name Last name Previous surname Marital status Single Married/de facto Divorced/widowed Date of birth DD / MM / YYYY Gender Male Female Height cm or Feet Inches Weight kg or Stone Pounds Have you smoked tobacco or any other substance in the last 12 months? Yes No If yes, please answer the following questions: Smoked cigarettes? Yes No If yes, what daily quantity is consumed? Smoked cigars or pipe? Yes No Smoked another substance? Yes No What is the purpose of the cover being applied for? Key person Partnership/Share Purchase Loan Cover Personal Combination 2. Contact Details Residential address (Do not enter a PO Box in this field) Is this your mailing address? Yes No Transfer of Insurance to SMSF or Investment Platform page 2 of 9

3 2. Contact Details Continued If no, please complete below. Mailing address Telephone and Preferred contact number 1 Home Business Mobile Preferred time 1 (AEST): 8am-7.30pm 8am-11am 11am-2pm 2pm-5pm 5pm-7.30pm Preferred contact number 2 Home Business Mobile Preferred time 2 (AEST): 8am-7.30pm 8am-11am 11am-2pm 2pm-5pm 5pm-7.30pm 3. Doctor/Clinic Details Do you have a GP or medical practice that you usually attend? Yes No If yes, please complete below: Name Contact number Contact type: Business Mobile How long ago was your last consultation with this GP or medical practice? Less than 6 months 6 to 12 months 1 to 2 years 2 to 5 years 5 years or more How long have you been attending this GP or medical practice? Less than 6 months 6 to 12 months 1 to 2 years 2 to 5 years 5 years or more If less than 2 years, or you don t currently have a GP or medical practice that you usually attend, please advise the name and contact details of your previous GP or medical practice attended: Name Contact number Contact type: Business Mobile Transfer of Insurance to SMSF or Investment Platform page 3 of 9

4 4. Health & Lifestyle Details 1. In the last five years have you had any symptoms of illness and/or injury, or any condition (other than cold/flu/contraception) for which you sought medical advice and/or treatment? Yes No 2. In the last five years have you had any medication prescribed (other than contraceptives and/or antibiotics)? Yes No 3. In the last five years have you had any medical test(s), investigations or procedures (e.g. ECG, genetic test, colonoscopy, endoscopy, gastroscopy or ultrasound)? Yes No 4. Apart from any condition already disclosed, do you plan to seek medical advice, investigation or treatment for any other current health condition? Yes No 5. Have you ever injected, smoked or otherwise taken recreational or non-prescription drugs, taken any drug other than as medically directed or received advice and/or counselling for excess alcohol consumption from any health professional? Yes No 6. (i) In the last 5 years have you engaged in unprotected anal sexual intercourse, except in a relationship between you and one other person only, and neither of you has had sexual intercourse with anyone else in the last 5 years? Yes No (ii) In the last 5 years have you engaged in sexual intercourse with, or as, a sex worker? Yes No (iii) In the last 5 years have you engaged in sexual intercourse with someone you know, or suspect to be, HIV positive? Yes No 7. Do you currently participate in, or you do have any intention of participating in, any sports or hazardous activities (eg aviation, football, scuba diving, dirt bike riding, motor racing, rock climbing)? Yes No 8. Are you an Australian citizen or do you have an Australian Permanent Resident s visa? Yes No 9. In the next 12 months do you have any plans to travel or live overseas or are you required to travel on a regular basis for business? Yes No Transfer of Insurance to SMSF or Investment Platform page 4 of 9

5 5. Family History 1. Has any of your immediate family (mother, father, brother or sister) suffered from any of the following? Yes No Bowel or breast cancer; Heart disease or stroke; Cardiomyopathy; Type 1 or type 2 diabetes; A neurological condition such as Alzheimer s disease or Multiple Sclerosis; or Any hereditary condition? If yes, please advise relevant condition, number of relatives affected and age(s) at diagnosis: 6. Occupation Details To be completed for TPD application 1. Occupation 2. Employer s name 3. Average hours worked per week hours 4. Outline the duties of your main occupation: Duty % of time Administrative/clerical % Light manual % Supervisor of manual work % Manual work % 5. Are you self employed? (This means you are a business owner, sole trader, an employee of your own company or trust, or are in a partnership.) Yes No 6. Has your occupation or employment status changed (eg from employed to self employed) in the last 5 years? Yes No 7. Income Details Annual salary/remuneration package (gross)* $ * If self employed, this means your share of net business income (Gross business income or Turnover less business expenses) plus any items such as salary and superannuation not already included that are paid to you as a direct result of your personal exertion. If employed, this means your current wages or salary, award superannuation contributions, bonuses, commission, fees, fringe benefits and regular overtime. Transfer of Insurance to SMSF or Investment Platform page 5 of 9

6 8. Other Insurance Details To be completed for Life, TPD and Critical Illness insurance applications 1. Apart from this application, do you have or are you applying for any other Life, TPD or Critical Illness insurance (please include cover held under superannuation)? Yes No A. Is this other insurance being completely replaced by this application? Yes No If no, what will be the total amount of cover in force on your life (including this application)? Note: please include any TPD benefits under Critical Illness type contracts. Financial evidence may be required if total combined cover exceeds our financial underwriting limits. Life $ TPD $ CI $ 9. Policy Owner Policy owner Owner type Platform superannuation fund SMSF Trustee name ABN/ACN Contact number Contact type: Home Business Mobile 10. Preferred Risk Commencement Date (Optional) Please indicate a Preferred Risk Commencement Date if you are replacing cover DD / MM / YYYY that is held elsewhere. Note: You may select a future date between 1 and 60 days from the current date. If TAL is not able to issue the policy by the nominated date, a revised commencement date may apply. If this happens, we will contact your adviser to confirm the revised commencement date. Your Duty of Disclosure applies even after this application is completed and until TAL advises acceptance of insurance and issues a Policy Schedule. 11. Method of Payment Method Cheque Direct Debit Credit Card Platform Frequency Monthly Quarterly Half-yearly Yearly 12. Direct Debit Payment Authority by Credit Card I authorise the debit of my premiums from my: Visa MasterCard Account name Card number Expiry date MM / YYYY cardholder* Date DD / MM / YYYY * Signature(s) only required when the payer is not the Life Insured or Policy Owner. Transfer of Insurance to SMSF or Investment Platform page 6 of 9

7 13. Direct Debit Authority I request and authorise TAL Life Limited (Direct Debit System User Identification Number ) to directly debit my premiums, from my account detailed below, using the Bulk Electronic Clearing System (BECS). I confirm that I have read the Direct Debit Request Service Agreement in the Product Disclosure ment (PDS) and that I have the authority to make these payments. Account name Name of bank BSB number Account number account holder 1* Date DD / MM / YYYY account holder 2* Date DD / MM / YYYY * Signature(s) only required when the payer is not the Life Insured or Policy Owner. 14. Direct Debit from a Platform Account Important Note: Direct Debit from a superannuation or investment platform account is only available where TAL has an agreement with the platform provider. Platform name Account/member number Account name 15. Self-Managed Superannuation Fund Service Details Please provide details where TAL has an agreement with your SMSF Service provider. SMSF Service Provider: Account Name: Account Number (fund ID): Transfer of Insurance to SMSF or Investment Platform page 7 of 9

8 16. Policy Declaration I/we declare that I/we have read the following statements, and I/we agree and acknowledge that: I/we have received a copy of the Accelerated Protection, or Accelerated Protection for Investment Platforms, Product Disclosure ment (PDS), dated 12 December 2014; I/we have read and understand the Duty of Disclosure as set out in the PDS and understand the Duty of Disclosure also applies to Interim cover and that the Duty of Disclosure continues to apply until TAL accepts this application and issues a Policy Schedule; I/we have provided TAL with true, accurate and complete answers in my/our application (including Application Form, quotes and all other forms, questionnaires and information provided to TAL), whether answered by me/us or my adviser, to the best of my/our knowledge; Where my/our application has been submitted electronically to TAL, I/we will review; a printout of the application submitted and will notify my/our adviser of any answers which are incorrect, incomplete or inaccurate; or a summary received by (if I/we have provided TAL with an address for the purpose of receiving a summary of the application by ) and will notify TAL of any answers which are incorrect, incomplete or inaccurate within five business days; I/we will cooperate with TAL if modifications to the Policy conditions are required because of any changes to the answers TAL are notified of; I/we understand that by signing this form, I/we consent to TAL s collection, use and disclosure of my/our personal information in accordance with the section in the PDS headed Your Privacy ; I/we understand that my/our financial adviser is my/our agent and not the agent of TAL; I/we understand that TAL may accept information from my/our financial adviser, or their representative, and that TAL will rely on any such information in deciding whether or not to accept my/our application and in relation to all matters of administration; In relation to any tax returns submitted in support of this application I/we confirm that these are the tax returns submitted to the Australian Taxation Office and no subsequent adjustments have been made or are expected; In the event that TAL determines to not accept my/our application on standard terms; I/we authorise TAL to inform my/our financial adviser, or their representative, of the reasons for that decision. I/we understand that TAL will not provide copies of medical or other reports to my financial adviser, or their business, without first obtaining my/our consent; and I/we authorise my/our financial adviser, or their representative, to communicate to TAL my/our acceptance of any alternative terms on my/our behalf; and I/we have authorised TAL to debit my/our premiums if credit card or bank account details are provided with my application. life to be insured SIGN HERE Date DD / MM / YYYY policy owner 1 If different to the Life Insured SIGN HERE Date DD / MM / YYYY policy owner 2 If different to the Life Insured SIGN HERE Date DD / MM / YYYY Transfer of Insurance to SMSF or Investment Platform page 8 of 9

9 17. Medical Evidence Authority Reference number Date of birth DD / MM / YYYY Name of life to be insured Dear Doctor I have applied to TAL Life Limited (TAL) for insurance and a medical report from your practice is required. Until this report is received by TAL my application for insurance cannot proceed. I have agreed that any Medical Practitioner or any other person who has been or may be consulted by me at any time in the future whether named by me or not shall be and is hereby authorised and directed by me to divulge to TAL, any legal tribunal or any third party engaged by TAL all medical or surgical information acquired with regard to myself. A photocopy or facsimile of this authority shall be considered as valid as the original. I would be grateful if you could attend to this matter as soon as possible. life to be insured Date DD / MM / YYYY 18. Authorised Representative Details Principal Authorised Representative TAL adviser number Authorised Rep name Dealer group Commission split (whole numbers) New business % Servicing % Contact number Contact type: Business Mobile Shared Authorised Representative TAL adviser number Authorised Rep name Dealer group Commission split (whole numbers) New business % Servicing % Note: If splitting commission, new business and servicing commission must each total 100%. Please return the completed form to: TAL Life Limited, GPO Box 5380 Sydney NSW 2001 T F E accelerateservice@tal.com.au Transfer of Insurance to SMSF or Investment Platform page 9 of 9