Permanent Disability Benefit Guide. Issued: December 2013

Transcription

1 Permanent Disability Benefit Guide Issued: December 2013

2 Contents Your insurance... 3 Permanent disability benefit... 4 How is my benefit calculated?... 6 How is my benefit paid?... 7 Review and appeal process... 8 Need more information?... 9 Contact Centres 70 Eagle Street Brisbane 63 George Street Brisbane Ph ( if overseas) Fax ( if overseas) Monday to Friday 8.30am to 5.00pm AEST GPO Box 200 Brisbane Qld 4001 qsuper.qld.gov.au This information is provided by the fund administrator, QSuper Limited (ABN AFSL ) which is ultimately owned by the QSuper Board (ABN ) as trustee for the QSuper Fund (ABN ). This information has been prepared for general purposes only without taking into account your objectives, financial situation, or needs and should not be relied on as legal or taxation advice, nor does it take the place of such advice. Any statements of law or proposals are based on our interpretation of the law or proposals as at the time of printing. As a result, you should consider the appropriateness of the information for your circumstances and read the product disclosure statement (PDS) before deciding whether to acquire, or continue to hold, a product. You can obtain a PDS at qsuper.qld.gov.au or by calling us on All products are issued by the QSuper Board as trustee for the QSuper Fund. Where the term QSuper is used in this document, it represents the QSuper Board, the QSuper Fund and QSuper Limited, unless expressly indicated otherwise. 2 Permanent Disability Benefit Guide December 2013

3 Your insurance Your QSuper insurance covers you 24 hours a day, seven days a week. If you re employed by a Queensland Government or related entity employer, your insurance is automatically provided to you when you start work. If you re not employed by the Queensland Government or related entity your insurance cover is provided through TAL Life Limited 1 under a group insurance arrangement with QSuper. TAL is responsible for assessing your claim and making a recommendation to the QSuper Board of Trustees about the eligibility of your claim. Important information about your total and permanent disability claim If we receive an employer contribution for you, an insurance benefit may be payable to you. Regardless of whether you have death and TPD insurance cover or not, you may be eligible to access your superannuation early. QSuper is responsible for assessing your eligibility for access to your superannuation and administering your claim. How do I apply for a permanent disability benefit? The process of investigating whether you re eligible for a permanent disability can be started by: you your employer QSuper (if you re already receiving an income protection benefit and medical evidence suggests you may not be able to return to your normal position). If you or your employer requests QSuper investigate a permanent disability benefit, a detailed medical report addressing specific questions will be required from your treating medical specialist. Please note you, or your employer, will be responsible for the cost of this initial report if it s required. QSuper will pay for the costs of any subsequent medical information required to assess your claim. To claim a benefit you ll need to complete the Permanent Disability Benefit Application and have your medical practitioner/specialist complete the Doctor s Statement at the back of this guide. Please call us if you need help to complete this form. The completed documents then need to be sent to QSuper: Member s Statement (to be completed by you) Employer s Statement (to be completed by your employer) Doctor s Statement completed by your treating medical practitioner or specialist please note you are responsible for any fees involved in having this form completed a copy of any additional medical reports or medical certificates that you may have in relation to your injury or illness a certified copy of your proof of age (i.e. birth certificate, passport or driver s licence). A certified copy is a photocopy of the original document signed by any of the qualified certifiers listed on the Providing Proof of Identity factsheet. Financial advice QInvest 2 offers affordable personal financial advice to QSuper members on a range of topics covering superannuation, retirement planning, wealth creation, salary packaging and personal life insurance. QSuper contributes towards the cost of our members seeking personal advice from QInvest about their QSuper benefit. 3 Members only pay part of the total cost of QSuper related advice, called an advice fee. If you re seeking advice about other super or retirement matters (other than your QSuper account), the amount of your advice fee will vary depending on your situation, the nature of the advice and whether you seek advice over the phone or face to face. You can choose between your advice fee being deducted from your QSuper account balance or made as a payment from your personal finances. Information about QInvest fees is available on the Financial advice section of our website at qsuper.qld.gov.au/advicecosts. QInvest will advise you of the fee before providing you with advice. For more information or to make an appointment with a financial adviser, visit QInvest online (qinvest.com.au) or call TAL Life Limited, ABN QInvest Limited (ABN , AFSL and Australian Credit Licence number ) (QInvest) is ultimately owned by the QSuper Board (ABN ) as trustee for the QSuper Fund (ABN ), and is a separate legal entity which is responsible for the financial services and credit services it provides. 3 The circumstances where QSuper won t be able to contribute towards the cost of advice include where: (i) you have more than two advice appointments in a financial year; (ii) the advice doesn t relate to your QSuper benefit; (iii) you require assistance with implementing your advice or require periodic reviews; or if you have recurring advice needs. Permanent Disability Benefit Guide December

4 Permanent disability benefit How is my claim assessed? A claims manager will be allocated to manage your entire claim and will contact you when they have been assigned to your claim. They ll also be able to discuss the claims process with you and answer any specific questions you may have in relation to the assessment of your claim. If your insurance cover is provided by TAL, we ll forward your completed documentation to TAL, who will allocate a claims manager to manage your claim throughout its duration. When administering claims for disability benefits, QSuper and TAL Life Limited focus on best practice in all aspects of claims management. We manage claims professionally and promptly and provide a high quality level of service to all our members. QSuper or TAL may request additional information prior to making a decision about your claim, which could include: requesting further medical reports in relation to your medical history or illness/injury arranging for you to be examined by an independent medical specialist requesting additional financial information in order to calculate your benefit. The costs associated with QSuper or TAL s requests for any additional medical information will be met by the insurer. What if my insurance claim isn t approved? If your claim isn t approved, you ll be provided with copies of all evidence obtained in relation to the decision by TAL Life Limited and the QSuper Board of Trustees, as well as a detailed statement outlining the reasons for the decision. What if I m receiving a QSuper income protection benefit? An income protection benefit is payable for temporary disability and will end if your disability becomes permanent. For more information, you can download a copy of the Income Protection Benefit Guide from our website or call us and we ll send you a copy. 4 Permanent Disability Benefit Guide December 2013

5 Permanent disability benefit What if I have a terminal medical condition? If you are suffering from a terminal medical condition you may submit a claim to gain access to your superannuation and potential insurance benefits. The release of these benefits as a result of a terminal medical condition requires two medical practitioners, with at least one of the practitioners specialising in the area relating to the illness or injury you re suffering, to certify that the illness or injury is likely to result in your death within 12 months from the date of certification. You ll find more information about eligibility and tax on terminal medical condition benefit payments in the Accumulation Account Guide. You can download this from our website, or call us and we ll send you a copy. If you intend to claim these benefits, you ll need to complete the Terminal Illness Claim form which you can download from our website. What happens if I die? Death benefits for contributing QSuper members are calculated in the same way as TPD benefits. Your superannuation benefit doesn t automatically form part of your estate. Upon your death, QSuper can pay your death benefit to your legal representative (that is, the executor or administrator of your estate) or any other person the QSuper Board determines to be appropriate. This may include your spouse, your children, someone who is in an interdependent relationship with you or a financial dependant. You have the option of making a binding death benefit nomination, which allows you to nominate who receives your superannuation benefit in the event of your death. However, you can only nominate your legal personal representative and/ or one or more of your dependants, who must still be dependants at the time of your death. For more information, refer to the Making a Binding Death Benefit mination factsheet. You can download this factsheet from our website, or call us and we ll send you a copy. If you have a Defined Benefit, State or Police account, a pension may also be paid to your dependent children if: you die, or you receive a lump sum TPD benefit and, within 12 months of that payment, die from the same condition that resulted in the TPD benefit or a related condition. Permanent Disability Benefit Guide December

6 How is my benefit calculated? Accumulation account If you have an Accumulation account, your TPD benefit is a specific dollar value based on the number of units of insurance you hold. When you reach age 65 your TPD cover ceases and you have death-only cover from age 65 to 70. Death and TPD insurance cover for police officers 1 ends at age 60. The value of a unit changes depending on your age. The automatic cover provides you with either two or four units of death and TPD insurance, depending on your employment arrangements, 2 and you may purchase additional units. The maximum value of insurance you can hold through QSuper and TAL is $2 million. Your benefit will include this amount plus the balance of your Accumulation account at the time you make a claim. Defined Benefit account If you have a Defined Benefit account and are under age 55, your payment will have two parts: your current accrued benefits including any extra funds you may have in an Accumulation account your insurance benefit, which is the amount by which your Defined Benefit account would have grown if you had remained a member of the Fund up to age 55 (your prospective benefit). If you work part time, an adjustment is made to the prospective service part of your TPD benefit to reflect the pattern of your employment. If you re 55 or over, your payment will be your current accrued benefits only. You may be entitled to extra benefits if you have additional death and disability cover. The age limit for additional disability insurance cover is 65 and additional death-only insurance ceases at 70. Proportional benefits If you aren t employed by the Queensland Government or a related entity and we have received employer contributions for you and you applied for standard insurance, there may be a proportional benefit available within the five year pre-existing exclusions period. If you were at work on 16 December 2013, the pre-existing condition exclusion period reduced to a maximum of five years for your existing level of standard insurance cover and additional insurance cover. Proportional benefits (as shown in the table below) may be payable in the event of death, disability or terminal illness if it s related to a pre-existing medical condition, and it occurs between the second and fifth year of continuous insurance cover. Period of insured membership Up to 2 years 0% Between 2 years and 4 years 11 months 5 years or more 100% You can find out how much cover you have by: logging into Member Online reading your latest benefit statement checking your Welcome letter calling us on Percentage of standard insurance benefit 10% x sum insured + 2.5% x sum insured for each full month of continuous cover after 2 years 1 Different insurance arrangements apply to police officers. 2 For more information on your cover eligibility for automatic cover please refer to the Accumulation Account Insurance Guide. 6 Permanent Disability Benefit Guide December 2013

7 How is my benefit paid? Lump sum payment options 1. Leave your benefit in a QSuper Accumulation account With a QSuper Accumulation account you can select a number of investment options, ranging from lower risk/ lower return to higher risk/higher return and there are no entry or exit fees just one low management fee. More information is available in the QSuper Accumulation Account Product Disclosure Statement (PDS). You can download this from our website, or call us and we ll send you a copy. You can withdraw amounts over $2,000 from the unrestricted non-preserved component of your Accumulation account at any time. You can also deposit other money into your account, including superannuation from other funds and voluntary contributions. 3. Cash your QSuper benefit You may be able to take all or part of your QSuper benefit as cash, but you need to be aware that some components of your benefit may be subject to tax. More information on tax is available in the Tax Explanation factsheet. You can download this from our website or call us and we ll send you a copy. 4. Roll over to another complying superannuation fund You can roll over all or part of your QSuper benefit to another complying superannuation fund. If you re considering this option, you might like to compare QSuper s range of educational tools, service and solid returns before making your decision. 2. Transfer your benefit into an Income account With an Income account your funds are invested while you draw a regular income which is paid until your funds run out. You can choose how large or small your payments are (within legislated guidelines) and how often you receive them. To open an Income account you must deposit at least $30,000. You can t invest extra money into the account after this initial deposit, but you can open one or more additional Income accounts and draw a separate income from each. Choosing the award winning 1 Income account to fund your retirement means that you continue to benefit from our low fees and proven solid returns. 1 Inaugural Chant West Conexus Financial Super Awards Permanent Disability Benefit Guide December

8 Review and appeal process Defined Benefit account holders Permanent and partial disability To be entitled to a permanent and partial disability (PPD) benefit you must be disabled to a degree which, in the opinion of the QSuper Board, after considering relevant medical opinions, you re permanently unfit or permanently incapable of discharging the duties of your office efficiently, but your illness or injury isn t a total and permanent disablement. How is my benefit calculated? The PPD benefit is equivalent to your current accrued benefit. It may be made up of two parts: an unrestricted non-preserved (cashable amount) and/or a preserved amount. The unrestricted non-preserved amount is the portion of your benefit you can withdraw from your super account immediately. It consists of your personal contributions and returns, plus a part of the employer financed portion of your benefit paid into your account before 1 July This amount is shown on your benefit statement. This benefit is payable as a lump sum only and will be payable regardless of any pre-existing medical condition. The other part of your benefit is preserved until you retire after reaching your preservation age, and must remain invested in either QSuper or another complying superannuation fund. More information is available in the Defined Benefit Guide. You can download this from our website or call us and we ll send you a copy. What is the review and appeal process? If you re not satisfied with QSuper or TAL s decision regarding your claim, you may lodge an appeal and have the matter reviewed internally by QSuper and/or TAL. In the event that you re still dissatisfied with the decision you may appeal to the QSuper Board of Trustees. All appeals must be made in writing to: Legal Review Unit QSuper Group Life Insurance GPO Box 200 Brisbane Qld 4001 Please note you ll be responsible for the costs of any additional medical reports that you want to provide in support of your appeal. If you re still not satisfied after an internal review by TAL and consideration by QSuper, you may lodge a complaint with the Superannuation Complaints Tribunal (SCT) within two years of the date of the original decision. What is the Superannuation Complaints Tribunal? The Superannuation Complaints Tribunal (SCT) is an independent body, established by the Australian Government, to resolve disputes between superannuation funds and their members and/or potential beneficiaries if the internal complaints procedure of the superannuation fund has failed to resolve the complaint. Acting as a mediator, the SCT aims to resolve issues by mutual agreement. If a mutual agreement can t be reached, the SCT may review the matter and make a binding decision. The complaints which the SCT can deal with are limited, and it s possible they can t deal with your case. They will advise you if they can deal with your complaint and, if so, what information you ll need to supply. You can contact the SCT at: The Secretariat Superannuation Complaints Tribunal Locked Bag 3060 Melbourne Vic 3001 Phone: info@sct.gov.au 8 Permanent Disability Benefit Guide December 2013

9 Need more information? We re committed to making it easier for you to understand your options, so you can feel confident that you re making the right choices for your super. If you have any questions about this guide or your super in general, call us or visit our website for useful information, tools and calculators. Written enquiries can be addressed to: QSuper GPO Box 200 BRISBANE QLD 4001 Ph qsuper.qld.gov.au Permanent Disability Benefit Guide December

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11 Permanent Disability Benefit Application Please complete in dark blue or black ink. What do I use this form for? Before we can assess your application for a permanent disability benefit, we need detailed information regarding your employment and the nature, cause and extent of your medical condition or injury. We also need to know who your current treating medical practitioners are as we may need to contact them for further information. All sections of the form need to be completed. Section 1 QSuper account details Client number! You can find your client number on your benefit statement Section 2 Personal details Mr/Mrs/Ms/Miss/Dr/other (please specify) Surname Given names Postal address State Postcode Residential address State Postcode Date of birth (dd/mm/yyyy) Previous name 1 Phone number (home) Phone number (work) Phone number (mobile) address 1 If your name has changed since you last had contact with QSuper, please contact us for information on the additional documents you will need to provide. Preferred method of contact. Post Phone Employment status. (S/E) Full-time Part-time Casual Other (including unemployed) If other or unemployed please specify Section 3 Details of your illness or injury Please enclose copies of any medical information you have, such as WorkCover Queensland records or Veteran s Affairs assessments that may be useful in considering your claim. Name of illness or injury ( illness or injury is not sufficient) Cause Are you receiving, or willing to receive, appropriate medical care as recommended by your treating medical practitioners? When did you first start to experience signs or symptoms? (dd/mm/yyyy) When was the illness first diagnosed or date of injury? (dd/mm/yyyy) When did you first approach a medical practitioner in relation to your illness or injury? (dd/mm/yyyy) What was your base salary prior to your illness or injury? (hourly) $ 1/8

12 Permanent Disability Benefit Application continued Section 3 Details of your illness or injury (continued) Name of employer If you have previously suffered a similar illness or injury, please provide details of the name of the illness or injury, the approximate date it was diagnosed, the doctor you saw and the treatment you received. Name of illness or injury ( medical condition is not sufficient) Approximate date diagnosed (dd/mm/yyyy) Doctor s name Doctor s address Doctor s phone number State Postcode Treatment Have you been able to work in any job, whether full-time or part-time, paid or unpaid, since you became disabled? If so, please give details. Do you intend to return to work? If no, please provide details If yes, when do you expect to return to work? (dd/mm/yyyy) Do you require rehabilitation assistance? (please specify below) Has a return to work program been discussed with your doctor? (please specify below) What was the outcome of these discussions? Do you need assistance with the following activities? / If yes, please describe the type of assistance you require and your limitations in performing these activities. Dressing (e.g. putting on and taking off clothes) Bathing (e.g. washing and showering) Toileting (e.g. using the toilet - including getting on and off) Mobility (e.g. walking, getting in and out of a chair or bed) Feeding (e.g. getting food from a plate to your mouth) Domestic duties (e.g. cooking and cleaning) 2/8

13 Permanent Disability Benefit Application continued Section 4 Medical practitioner details Please provide details of your current treating medical practitioner(s) and/or specialist(s). Practitioner 1 Name Phone number Postal address State Postcode Specialty Date first contacted (dd/mm/yyyyy) Date last contacted (dd/mm/yyyyy) Practitioner 2 Name Phone number Postal address State Postcode Specialty Date first contacted (dd/mm/yyyyy) Date last contacted (dd/mm/yyyyy) Practitioner 3 Name Phone number Postal address State Postcode Specialty Date first contacted (dd/mm/yyyyy) Date last contacted (dd/mm/yyyyy) Practitioner 4 Name Phone number Postal address State Postcode Specialty Date first contacted (dd/mm/yyyyy) Date last contacted (dd/mm/yyyyy) Practitioner 5 Name Phone number Postal address State Postcode Specialty Date first contacted (dd/mm/yyyyy) Date last contacted (dd/mm/yyyyy) If you have consulted further doctors/specialists or health professionals, please provide their details as a separate attachment. Continued over page 3/8

14 Permanent Disability Benefit Application continued Section 5 Recreational activities Please describe your hobbies/interests/social activities. Does your condition restrict your ability to undertake these activities? If yes, please describe how you are restricted. Section 6 Other entitlement details Have you claimed a permanent disability benefit in the past? Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Have you claimed, or do you intend to claim, other insurance for this illness or injury? Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Have you claimed, or do you intend to claim, Department of Human Services entitlements for this illness or injury? Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Have you claimed, or do you intend to claim, a benefit from WorkCover Queensland for this illness or injury? Start date (dd/mm/yyyy) End date (dd/mm/yyyy) If you are claiming any other insurance or entitlements, please provide your: Case manager s name Case manager s phone number Claim reference number 4/8

15 Permanent Disability Benefit Application continued Section 7 Job details and employment history Please describe your job in detail. What particular duties are/were you prevented from doing? What particular duties are/were you able to do? What educational qualifications, degrees, certificates or specific work skills do you have? Please give details of previous employment (approximate dates are suitable). Position Employer Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Position Employer Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Position Employer Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Position Employer Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Are you still employed? Do you manage or supervise staff? If yes, how many? Continued over page 5/8

16 Permanent Disability Benefit Application continued Section 7 Employer Job details and employment history (continued) District/school/region (only for members employed by the Queensland Government) Position/title Payroll number Manager s name Manager s phone number When did you first stop working as a result of your illness or injury? (dd/mm/yyyy) If you have terminated your employment, was it due to this illness or injury? If yes, please specify the exact date this occurred (dd/mm/yyyy) and the name of your employer. Please complete if you are self-employed What were your income and expenses for the last 12 months (pre-disability)? Gross income from occupation $ Expenses $ What were your income and expenses for the last 24 months (pre-disability)? Gross income from occupation $ Expenses $ 6/8

17 Permanent Disability Benefit Application continued Section 8 Authority to access and release medical details I give my consent to QSuper, its agents and advisers to contact medical practitioners I have consulted, including but not restricted to those listed and to contact other organisations, including WorkCover Queensland, the Department of Human Services, Q-COMP, the Department of Veterans Affairs, insurance companies and my employer who may have medical or other details that may be relevant to my disability claim. I authorise those medical practitioners and bodies to release such details (which may include sensitive or health information) to QSuper, its agents and advisers as may be requested. I further consent to QSuper releasing medical and other information (which may include sensitive or health information) to my employer, WorkCover Queensland, medical and allied health advisers, and agents who may be asked to provide reports and/or opinions relating to my disability claim. I understand and agree that if I don t sign this authority, which is required for the proper administration of QSuper, or if I don t give information requested by QSuper or its representatives, QSuper may not be able to assess my claim. Signature! A photocopy of this consent and authorisation is as valid as the original. Date (dd/mm/yyyy) Section 9 Medical authority This section to be completed by claimants not employed by the Queensland Government or a related entity. I hereby authorise any doctor, hospital, therapist or other Name medical professional who has attended me to release to TAL Life Limited, QSuper (or their representatives) information Signature relevant to my policy and/or claim, with respect to any illness or injury, medical history, consultations, medications or treatment received by me, together with copies of any and all medical records. I consent to TAL Life Limited and QSuper collecting this sensitive information. A copy of this authority is to be regarded Date (dd/mm/yyyy) as if it were the original signed authority. Continued over page 7/8

18 Permanent Disability Benefit Application continued Section 10 Declaration and authorisation I declare the information included in this application is, to the best of my knowledge and belief, true and correct, and that no relevant information relating to this claim has been withheld. I agree to provide all medical information requested and to undertake any medical or occupational assessments considered appropriate by QSuper. Signature Date (dd/mm/yyyy) Checklist Please use this checklist to ensure you have fully completed the Permanent Disability Benefit Application form and submitted all required supporting documentation. I have provided all the relevant information in Section 2 I have provided details on my condition in Section 3 and the attached copies of any medical evidence I already have on my condition, and any other relevant information. I have provided details of my recent medical practitioners in Section 4 If I m claiming any other entitlements, I have provided details in Section 6 I have completed my job details and employment history in Section 7 I have completed and signed the Authority to access and release medical details in Section 8 (only if employed by the Queensland Government or a related employer) I have completed and signed the medical authority in Section 9 (only if not employed by the Queensland Government or a related entity) I have signed the QSuper declaration in Section 10 18/6 8/8 Contact Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone ( if overseas) Monday Friday 8.30am to 5.00pm AEST QSuper Board of Trustees 2013 Postal address GPO Box 200 Brisbane Qld 4001 Fax (07) Website qsuper.qld.gov.au ABN: SFN: /13 FO84 in IB25 This form is issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN ) (QSuper Board). All products are issued by the QSuper Board as trustee for the QSuper Fund (ABN ). The privacy of your personal information is important to us. QSuper Limited (ABN , AFSL ) is collecting this information on behalf of the QSuper Board to administer your superannuation account. This is authorised under the Superannuation (State Public Sector) Act This information may be disclosed to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. QSuper may also disclose this information to third parties if it is necessary in providing our products and services to you, or you have consented to the disclosure, or disclosure is required by law. If you would like further information about our privacy policy, you can download QSuper s Your Privacy factsheet from our website. Alternatively, call us and we ll send you a copy. Where the term QSuper is used in this form, it represents the QSuper Board, the QSuper Fund and QSuper Limited, unless expressly indicated otherwise.

19 Permanent Disability Benefit Application Employer s Statement This form is to be completed by non-queensland Government employers. Please refer to the additional information about the form on page 4. Please complete in dark blue or black ink. What do I use this form for? This part of the claim form should be completed by staff of the personnel section or pay office. Section 1 Employee s details Mr/Mrs/Ms/Miss/Dr/other (please specify) Surname Given names Date of birth (dd/mm/yyyy) Position/title Payroll number Date employee joined this company (dd/mm/yyyy) When did you start contributing to QSuper for this employee? (dd/mm/yyyy) Section 2 Name of employer Employer details Phone number (work) Phone number (mobile) Fax address Address of head office State Postcode Employee s work address Same as above Different (please provide below) Phone number (work) Fax State Postcode Section Part C 3 Salary details What was the basic monthly salary (gross) prior to the employee ceasing work? $ per month What was the package monthly (gross) prior to ceasing work? $ per month Please provide the components of the package below. Continued over page 1/4

20 Permanent Disability Benefit Application Employer s Statement continued Section 4 Employment status What is the employee s employment status? Self-employed Permanent full-time Permanent part-time Casual Other - including unemployed (please specify below) Please indicate the employee s present employment status, and where applicable include date. Still employed Resigned Terminated Redundancy Disability leave Retirement Other (specify below) (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) What were the average hours worked by the employee prior to their disablement? hours per week What date did the employee cease all duties? (dd/mm/yyyy)! Please note - this is not necessarily the date of termination from employment. Prior to the date the employee ceased all duties, were they working in a reduced capacity or on alternative or restricted duties? If yes, please provide reasons What was the reason for the employee ceasing work? Section 5 Return to work Are there alternative jobs that the employee would be able to perform if they are unable to return to their usual occupation? If yes, please provide alternative jobs If you answered yes, would you support a return to work program? Is there a return to work co-ordinator to assist the employee with an appropriate return to work plan? If so, please provide contact details. Name Phone number Mobile 2/4

21 Permanent Disability Benefit Application Employer s Statement continued Section 6 Physical work environment details Does the employee s job require them to work in any of the following conditions? Please tick the relevant column. Condition If yes, percentage of time Outside % In extreme cold and/or heat % In a damp or humid environment % In a noisy environment % In a dusty or unventilated environment % Around toxic fumes % During the employee s normal routine, what percentage of time does the job require the employee to lift or carry the following weights? Weight Never 1%-25% 26%-50% 51%-75% 76%-100% 23kg or over 9 to 22kg Under 9kg During the employee s normal routine, what percentage of time does the job involve the following activities? Activity Never 1%-25% 26%-50% 51%-75% 76%-100% Walking Walking on uneven ground Driving Reaching above shoulders Reaching at shoulder height Reaching below shoulder height Bending or crouching Kneeling or crawling How much time is the employee required to maintain the following activities before changing position or activity? Activity 0-30 minutes minutes minutes more than 90 minutes Sitting at one time Standing at one time Driving at one time During the average day, what is the average number of hours the employee spends in the following positions or activities? Activity 0-2 hours 2-4 hours 4-6 hours 6-8 hours Sitting Standing Driving What percentage of the employee s time is spent in the following activities? Talking Writing Supervising other people % % % Are you aware of any other claims being lodged by or on behalf of the employee? If yes, please provide details. Continued over page 3/4

22 Permanent Disability Benefit Application Employer s Statement continued Section 7 Supportive documents Please attach the following documents with your completed form. Please tick the box to confirm the attachments. Job description Rehabilitation reports and plans Proof of earnings (last two payslips) Leave reports (annual leave, sick leave) for the past 12 months Termination documents Any other information that will assist in the assessment of the employee s claim Section 8 Privacy and declaration Privacy laws protect the privacy of individuals. TAL Life Limited and QSuper request that any information received by or requested from you is handled in accordance with the regulations and the Australian Privacy Principles. If you would like to know more about QSuper or TAL s privacy policy, please refer to the TAL Life Limited website, tal.com.au/privacy-policy or the QSuper website qsuper.qld.gov.au. Name Signature Date (dd/mm/yyyy) Additional information about the form Insurance cover for members with non-queensland Government employment is provided through a group life policy issued by TAL Life Limited (ABN ) for the QSuper Board of Trustees (ABN ). The QSuper Board of Trustees owns this policy. This form should be completed in full, as assessment of this claim may be delayed if the information provided is incomplete. Please have this form completed by the employee s direct report if possible. 22/6 4/4 Contact Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone ( if overseas) Monday Friday 8.30am to 5.00pm AEST QSuper Board of Trustees 2013 Postal address GPO Box 200 Brisbane Qld 4001 Fax (07) Website qsuper.qld.gov.au ABN: SFN: /13 FO84 in IB25 This form is issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN ) (QSuper Board). All products are issued by the QSuper Board as trustee for the QSuper Fund (ABN ). The privacy of your personal information is important to us. QSuper Limited (ABN , AFSL ) is collecting this information on behalf of the QSuper Board to administer your superannuation account. This is authorised under the Superannuation (State Public Sector) Act This information may be disclosed to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. QSuper may also disclose this information to third parties if it is necessary in providing our products and services to you, or you have consented to the disclosure, or disclosure is required by law. If you would like further information about our privacy policy, you can download QSuper s Your Privacy factsheet from our website. Alternatively, call us and we ll send you a copy. Where the term QSuper is used in this form, it represents the QSuper Board, the QSuper Fund and QSuper Limited, unless expressly indicated otherwise.

23 Permanent Disability Benefit Application Doctor s Statement Please refer to the additional information about the form on the back page of this form. Please complete in dark blue or black ink. What do I use this form for? Before QSuper can pay you a benefit we need detailed information from your general practitioner or medical specialist about the nature, cause, and extent of your illness or injury. If there is a charge for completing this form, the payment is the responsibility of the claimant. Neither QSuper nor TAL Life Limited are responsible for paying the attending doctor. Section 1 Claimant s details Mr/Mrs/Ms/Miss/Dr/other (please specify) Surname Given names Date of birth (dd/mm/yyyy) Height (cm) Weight (kg) Section 2 Claimant s history Are you the claimant s usual general practitioner? If yes, what date did you first begin treating the claimant? (dd/mm/yyyy) If no, who referred the claimant to you? What date did you first see the claimant? (dd/mm/yyyy) Section 3 Medical and consultation details Is the claimant totally disabled and unable to work as a result of their current condition? If yes, from what date were they unable to work? (dd/mm/yyyy) When did the claimant s symptoms relating to this condition first occur? (dd/mm/yyyy) Please outline the claimant s initial symptoms relating to this condition. Has the claimant ever experienced these, or similar symptoms, previously? If yes, from when? (dd/mm/yyyy) If yes, please explain. Is the claimant permanently unable to perform the duties of their current role? Are they likely to ever resume in their own role or other roles in future? Continued over page 1/4

24 Permanent Disability Benefit Application Doctor s Statement continued Section 4 Medical and consultation details (continued) What was the date of your first consultation with the claimant in relation to this condition? (dd/mm/yyyy) Did the claimant see any other doctors prior to their first consultation with you? If yes, please provide the contact details of the doctor first seen and the date of this consultation? Name Practice Postal address Phone number State Date of consultation (dd/mm/yyyy) Postcode Who made the diagnosis of the claimant s condition? When was the diagnosis made? (dd/mm/yyyy) Please confirm the diagnosis of the claimant s condition. Section 5 Treatment and progress of medical condition What active treatment (including medication and dosage) has the claimant received from yourself and other practitioners since this condition was diagnosed? What tests or investigations have been conducted to date and what were the results of these tests? Has the claimant been referred to any consultant or specialist? If yes, please provide the contact details of the consultant or specialist. Name Practice Phone number Postal address State Postcode How often are you seeing the claimant at this time? When is their next appointment? 2/4

25 Permanent Disability Benefit Application Doctor s Statement continued Section 6 Treatment and progress of medical condition (continued) Do you believe the claimant has reached maximal medical improvement? If no, please elaborate. Please describe the claimant s current reported symptoms. Are these reported symptoms supported by objective findings? Has the claimant s symptoms changed in frequency or severity? If yes, please describe how. Section 7 Claimant s capacity to work What is your understanding of the claimant s occupation and their duties? Who certified the claimant as medically unfit to work? Is the claimant working at present?, part-time, full-time If no, when do you consider the claimant likely to be certified fit to return to work? (dd/mm/yyyy) Part-time Full-time What tasks related to the claimant s occupation are they unable to perform at this time? If yes, from what date was the claimant medically certified as fit to work? Part-time Is the claimant currently performing their usual work duties? Full-time If no, what duties is the claimant performing? How many hours is the claimant working per week at present? hours per week Section 8 Privacy and declaration Privacy laws protect the privacy of individuals. TAL Life Limited and QSuper request that any information received by or requested from you is handled in accordance with the regulations and the Australian Privacy Principles. If you would like to know more about QSuper or TAL s privacy policy, please refer to the TAL Life Limited website, tal.com.au/privacy-policy or the QSuper website qsuper.qld.gov.au. Signature Date (dd/mm/yyyy) Continued over page 3/4

26 Permanent Disability Benefit Application Doctor s Statement continued Additional information about the form Insurance cover for members with non-queensland Government employment is provided through a group life policy issued by TAL Life Limited (ABN ) for the QSuper Board of Trustees (ABN ). The QSuper Board of Trustees owns this policy. This form should be completed in full, as assessment of this claim may be delayed if the information provided is incomplete. Please have this form completed by your medical practitioner. 26/6 4/4 Contact Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone ( if overseas) Monday Friday 8.30am to 5.00pm AEST QSuper Board of Trustees 2013 Postal address GPO Box 200 Brisbane Qld 4001 Fax (07) Website qsuper.qld.gov.au ABN: SFN: /13 FO84 in IB25 This form is issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN ) (QSuper Board). All products are issued by the QSuper Board as trustee for the QSuper Fund (ABN ). The privacy of your personal information is important to us. QSuper Limited (ABN , AFSL ) is collecting this information on behalf of the QSuper Board to administer your superannuation account. This is authorised under the Superannuation (State Public Sector) Act This information may be disclosed to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. QSuper may also disclose this information to third parties if it is necessary in providing our products and services to you, or you have consented to the disclosure, or disclosure is required by law. If you would like further information about our privacy policy, you can download QSuper s Your Privacy factsheet from our website. Alternatively, call us and we ll send you a copy. Where the term QSuper is used in this form, it represents the QSuper Board, the QSuper Fund and QSuper Limited, unless expressly indicated otherwise.

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28 Contact Centres 70 Eagle Street Brisbane 63 George Street Brisbane Ph ( if overseas) Fax ( if overseas) Monday to Friday 8.30am to 5.00pm AEST GPO Box 200 Brisbane Qld 4001 qsuper.qld.gov.au IB /2013