Application to vary income protection cover Before completing this application please read the Insurance Handbook for Sole Traders at www.cbussuper.com.au/stcover 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 be reasonably expected to know, that 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 the Insurer before you renew, 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 the Insurer knows, or in the ordinary course of its business ought to know; as to which compliance with your duty 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 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. section 1 Personal details THIS STEP MUST BE COMPLETED in Full Please use CAPITAL letters and cross appropriate boxes Member number Title X Mr X Mrs X Miss X Ms X Other Date of birth D D M M Y Y Y Y Male X Female X First name(s) Family name Telephone (home) ( ) Telephone (mobile) Address Unit number Street number Street name Suburb/town State/Territory Postcode Your employment status Sole Trader Unincorporated Partnership Occupation Duties performed Email section 2 Increasing, varying or upgrading your Income Protection Cover By completing the application form, you have the opportunity to: Upgrade your Accident-only Income Protection cover to Accident and Illness cover. This will provide you with cover for both an Accident or Illness which first occurs after your cover commences Increase your units of cover for Accident-only cover or Accident and Illness cover to provide you with a greater monthly benefit (subject to the limits outlined in the Insurance Handbook for Sole Traders on page 19). Vary your waiting period from 30 days to 90 days Vary your benefit period from two years to five years You MUST fully complete all sections of this Application to vary income protection cover including Section 3 Personal Information if you are applying to upgrade to Accident and Illness cover, increase your number of units of cover, vary your benefit period to five years or alter your waiting period from 90 days to 30 days. If you are ONLY applying to vary your waiting period from 30 days to 90 days, please nominate this change in question 4 below and sign and date Section 5-Declaration. 1. Select one of the following options: X I wish to upgrade my Accident-only Income Protection cover or X I wish to increase the number of Accident-only units of cover to Accident and Illness cover 2. Provide your current Annual Taxable Income (ie. Your annual income for the last financial year before tax, but after business expenses were deducted) $ 3. How many units of either Accident and Illness cover or Accident- only cover do you wish to apply for (this should be the total number of units you require, as this will replace any existing units you may already have) Read page 19 of the Insurance Handbook for Sole Traders to help you calculate the number of units you need. The number of units you choose should not exceed the number needed to provide you with a benefit of 85 per cent of your Annual Taxable Income (rounded up to the next whole unit). 4. Choose your waiting period 30 days X 90 days X Your Income Protection cover will be provided with a standard waiting period of 30 days. However, you may choose to increase your waiting period to 90 days. This will reduce the cost of your cover, however if you claim you will not start to be paid disability benefits until you have been disabled for a continuous period of at least 90 days. If you do not choose a waiting period, a 30-day waiting period will automatically apply. 5. Choose your benefit payment period 2 Years X 5 Years X Your Income Protection cover will be provided with a standard benefit period of two years. However, you may choose to increase your benefit period to five years. If you do not indicate a benefit period, a two-year benefit period will automatically apply. Note: you can cancel or decrease your level of Income Protection cover at any time by completing an Application to decrease or cancel insurance cover form at www.cbussuper.com.au/decrease. If you wish to reapply at a later date, your cover will be subject to acceptance by the Insurer and Cbus. Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN 46 006 261 623 AFSL 233792 Cbus ABN 75 493 363 262 4461 10/13 Page 1 of 6
section 3 Personal information Section 3 must be completed in full This information will be treated in strict confidence and will be used or disclosed only for matters relating to your insurance entitlements. 1. What is your height? cm or; feet inches and weight? kg or stone pounds 2. Have you ever been paid, entitled to receive, or are presently applying for a TPD or Terminal Illness Benefit from any superannuation arrangement or any insurance policy? If you answer Yes to this question, your insurance may be affected. (Members who are eligible to receive or have ever been paid a Total and Permanent Disability Benefit (TPD) from any superannuation fund or insurance policy are not eligible to apply for Income Protection cover). Please indicate in the space at the end of this section when the claim was submitted, the type and cause of claim and outcome. 3. In the last 12 months, have you smoked tobacco in any form? If Yes please state form and daily quantity 4. Have you lost the sight of an eye(s) or the use of a limb(s) (limb includes the whole hand or foot), or do you have any defect of hearing? 5. To your knowledge, have you suffered from: (a) diabetes, epilepsy, multiple sclerosis, hepatitis B or C? (b) asthma or any other respiratory disorder (other than the common cold)? (c) chest pain, high blood pressure, heart complaint, paralysis, stroke, cancer or tumour of any type? (d) disease or complaint related to kidney, bladder, lung, bowel, liver, stomach or any blood disorder? (e) mental or nervous disorder or chronic fatigue syndrome? (f) any disease or injury to the neck, back, RSI or arthritis? (g) AIDS, AIDS-related complex, AIDS-related condition, or have you ever had a test for HIV (Human Immunodeficiency Virus) antibodies which has proven positive? If you have answered YES to any of the above questions, please provide details below: (a) nature of condition/complaint (b) date commenced (c) duration of injury/illness (d) time off work (e) details of any operation performed (f) degree of recovery (g) names and addresses of doctor(s) or hospital(s) consulted If you need more space for your response, please attach an additional page. 1. MEMBER INSURANCE HISTORY 1. Has Life, Disability, Accident and Sickness or Superannuation cover on your life ever been declined, deferred or withdrawn from any insurance company or accepted with a loading, exclusion or other than as applied? > Please provide full details (including dates, name of company and reason) 2. Have you ever made a claim for disability benefits under an Insurance, Superannuation or Worker s Compensation policy, Veteran s Affairs or under Social Security (including CTP and public liability)? > Please provide full details (including dates, cause of claim, type of benefit and amount paid, claim number and insurance company) 3. Other than this application, do you have or are you applying for any Life, TPD, Disability Income, Income Protection or Group Salary Continuance (GSC) with any other company? > Please provide full details Company Type of Policy Benefit Amount Owner To be replaced by this policy No Yes No No Yes Yes Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN 46 006 261 623 AFSL 233792 Cbus ABN 75 493 363 262 4461 10/13 Page 2 of 6
2. HABITS, ACTIVITIES AND RESIDENCE 1. Do you drink alcohol? > Please state type and weekly quantity 2. 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 on a recognised airline), motor racing of any kind, diving, football, parachuting, hang gliding, etc? > Please provide full details 3. Are you an Australian Resident (as defined in Insurance definitions on pages 33-36 of the Insurance Handbook for Sole Traders)? If you answer no, please provide details below: 4. Do you intend travelling overseas in the immediate future (i.e. next 2 years?) > Please give full details (where, when, duration and reason) 3. MEDICAL STATEMENT 1. Name and address of your Doctor Telephone ( ) 2. How long have you been a patient of this doctor? Years Months 3. Details of last medical consultation, including doctors, physiotherapists, chiropractors or ANY other health professional. Date Health Professional Address Reason Outcome/Result 4. Within the LAST THREE YEARS have you, other than advised previously: a. Consulted, been examined or treated by, or received advice from any doctor, psychologist, psychiatrist, counsellor, chiropractor, physiotherapist or other health care professional (naturopath, etc) or been in a hospital or been advised to have an operation? b. Either occasionally or regularly taken any drugs, stimulants, sedatives, tranquillisers, medications by mouth, by inhalation or by injection? 5. Have you EVER had an ECG, x-ray, transfusion, mammogram, surgery or any other investigation? 6. Have you EVER had any blood tests which revealed an abnormality, eg raised blood sugar, liver function or renal function results, or anaemia, etc? 7. Do you contemplate seeking any medical examination, advice, treatment or surgery in the future? Please provide full details for all YES answers below (if more space is required, please fill in the additional information at the end of this section. Dates From: To: Name and address of Doctor or Hospital, Clinic, etc Conditions, Medications Treatment and Time off Work Recovery % Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN 46 006 261 623 AFSL 233792 Cbus ABN 75 493 363 262 4461 10/13 Page 3 of 6
8. Have you EVER received any advice or treatment for: a. raised cholesterol, or circulatory disorder? b. shortness of breath, palpitations, or rheumatic fever? c. bronchitis? d. indigestion, hernia, gastric or duodenal ulcer, colitis or any other intestinal disorder? e. gall bladder disease? f. knee complaint or any disorder of the joints, bones or muscles (eg. gout, arthritis)? g. renal colic, stones or blood in the urine? h. depression, anxiety, or stress? i. melanoma, sunspots or growth of any kind? j. eczema, dermatitis, psoriasis or any other skin condition? k. tinnitus, hearing loss or any defect in hearing, sight or speech? l. anaemia, leukaemia, or haemophilia? m. thyroid or prostate disorder, any disorder of the reproductive organs, or sexually transmitted disease? n. persistent diarrhoea, unexplained weight loss, enlarged lymph glands, recurrent fever or night sweats? o. fits of any kind, recurrent headaches, dizzy spells or fainting attacks? p. any other physical impairment, congenital abnormality, deformity or symptoms of ill health, illness or injury? Females only q. Have you ever had any gynaecological conditions (eg endometriosis, abnormal pap smear, etc)? r. Have you ever had any complications of pregnancy or childbirth? s. Are you currently pregnant? If yes, what is the expected delivery date? D D M M Y Y Y Y t. Have you ever had a breast lump (even if you have not seen a doctor about it)? Please provide full details for all YES answers below (if more space is required, please fill in the additional information at the end of this section. Specific Condition Question Number Question Number Question Number 1. Date symptoms first started and description of symptoms 2. What was the condition and which part of the body was affected? 3. What was the medical diagnosis including results of x-rays and investigations? 4. What was the frequency (daily, weekly, etc) of attacks or symptoms? 5. What was the severity (mild/moderate/ severe) and duration of attacks or symptoms? 6. How long were you unable to work or perform your normal duties/activities? 7. If a hospital visit was required, please provide date and duration of your stay 8. What advice/treatment did you receive? 9. Are you still receiving treatment? If so, please advise nature and frequency of treatment. 10. When did you last suffer from any symptoms? 11. Degree of recovery (%) 12. Please supply name and address of all doctors or hospitals or other consultants Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN 46 006 261 623 AFSL 233792 Cbus ABN 75 493 363 262 4461 10/13 Page 4 of 6
4. FAMILY HISTORY Please cross No or Yes Does or has any member of your immediate family [father, mother, brother, sister] suffered from: Huntington s disease; or Polycystic kidney disease; or Familial adenomatous polyposis; or Muscular dystrophy; or Motor neurone disease; or Cystic fibrosis or any other hereditary disorder? If YES, state the name of the disease or disorder and the relationship of the family member: 5. QUESTIONS IN RELATION TO AIDS 1. Have you EVER been infected by the virus which causes AIDS (the Human Immunodeficiency Virus)? 2. Have you EVER sought or are expecting to receive treatment for AIDS or an AIDS related condition or have you ever had a positive test for HIV? 3. Have you EVER shared a needle or syringe for the injection of any drug, engaged in male to male anal sexual activity or worked as or engaged in sexual activity with a prostitute or someone you know or suspect to be HIV positive? NB if any of these questions are answered yes, we will send you a separate questionnaire. 6. OCCUPATION DETAILS 1. Do you trade in your own right as a Sole Trader or in an Unincorporated Partnership in which you and/your partners bear full personal responsibility for all of your business actions and liabilities? 2. Has your business been established to exclusively provide services to one client or organisation? 3. Has your business been established under a company structure and are you a shareholder, director or employee of that company? 4. For your primary occupation, are you eligible to receive Superannuation Guarantee contributions into Cbus or any other superannuation fund? 5. Do you work either full time or part time in an excluded occupation? (Refer to page 34 of the Insurance definitions section of the Insurance Handbook for Sole Traders.) Please provide full details of your self-employed business: How long have you operated this business? years months Percentage of business you own % Name of business Address of business How many employees do you have? (excluding yourself) How many hours per week do you work? 6. What are the main duties of your occupation? Postcode Duties (eg, office work, sales, supervision, manual) % of time 7. Have you completed an apprenticeship or do you hold an Australian Recognised Trade Certificate or a degree in the field in which you are working? > Please provide full details Type Name of institution where obtained Please note: The Insurer will determine your occupational status of manual, skilled trades or non-manual. 7. FINANCIAL DETAILS Please note that based on the financial information provided below, additional financial information may be needed. 1. If disabled, would all or part of your income continue? (eg other disability income policies, pension, investment, rental, company profit share, etc) > Please provide full details Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN 46 006 261 623 AFSL 233792 Cbus ABN 75 493 363 262 4461 10/13 Page 5 of 6
7. FINANCIAL DETAILS (continued) 2. Income details for the last two financial years: self-employed only (ie, sole trader or partner within an unincorporated partnership) Annual Amounts Year ended 30/06/20 Year ended 30/06/20 Gross income from business Less ALL business expenses Net income/profit before tax Your share of net income Add back: Any personal wages, salary Allowances (eg, car) Superannuation Payments to spouse (income splitting only) Other (eg, your share of depreciation, your share of profit from supporting service company/trust please specify) TOTAL NET EARNED INCOME NB - any amounts received as wages/salary/drawings/ must not be paid from past profits, capital or loans. 8. ADDITIONAL INFORMATION (to help clarify any issue) section 4 Doctor s authority For the purposes of assessing my eligibility for insurance, I authorise my current medical practitioner, and any other medical practitioner or health professional I have consulted or may consult in the future, or that Hannover Life Re of Australasia Ltd (HLRA) appoints to examine me, to disclose information about my health and related matters to HLRA. A photocopy of this authorisation will be as valid as the original. MEMBER S Signature X D D M M Y Y Y Y section 5 Declaration Declaration To be completed by ALL applicants I declare the answers I have provided in this Application to vary income protection cover form are true and correct and that I have not deliberately withheld any information. I acknowledge this declaration is part of an application for Income Protection and that making a false statement may invalidate my application. I also acknowledge that I have read the duty of disclosure and consequences of non-disclosure. I understand the information on this form will be reviewed by Cbus for the purpose of assessing my eligibility for increased insurance cover and it will be forwarded to the Insurer for further review. I acknowledge any variation in my insurance cover will not start until accepted by the Insurer. I acknowledge my entitlement for an insured benefit under Cbus is subject to the terms and conditions of the Fund s insurance policy. Furthermore: I understand that in order to assess and process my application, Cbus or its Insurer may need health and employment information about me. I consent to Cbus or its Insurer obtaining information about me from any medical practitioner or health professional that I have or may consult in the future, or that Cbus or its Insurer appoints to examine me. I understand if I or anyone else on my behalf makes a claim for a benefit, Cbus and the Insurer will need information about me in order to assess and process the claim. For this purpose, I hereby consent to Cbus or the Insurer obtaining information about me from any of the following: Medical practitioners that I have consulted at any time, any that Cbus or the Insurer wishes to appoint to examine me, legal practitioners, health service providers, legal tribunals and courts, investigation organisations or other consultants, other insurance or reinsurance companies, my past and present employers and interpreters. I understand I am only eligible to receive insurance cover under one Cbus account. For the purpose of this application and any claim for a benefit, I also consent to Cbus or the Insurer disclosing information about me to any of the organisations mentioned above, insofar as such disclosure is necessary for Cbus or its Insurer to perform its functions. I have read and carefully considered this declaration and the questions on this Personal Health Statement and I confirm that all the statements are true and correct in relation to me. X D D M M Y Y Y Y Note: this form must be received by Cbus no later than 31 days from the date you complete, date and sign it. Please send this completed form to: Cbus, Locked Bag 999, Carlton South, VIC 3053 Cbus Super SPIN: CBU0100AU Cbus Trustee is United Super Pty Ltd. ABN 46 006 261 623 AFSL 233792 Cbus ABN 75 493 363 262 4461 10/13 Page 6 of 6