QSuper Guide. Permanent Disability Benefit Guide

QSuper Guide Permanent Disability Benefit Guide Issued: 3 August 2015

2 Permanent Disability Benefit Guide Contents Your permanent disability insurance 3 How is my benefit calculated? 4 How is my benefit paid? 5 Review and appeal process 6 Permanent Disability Benefit Application form Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone 1300 360 750 (+617 3239 1004 if overseas) Monday Friday 8.30am to 5.00pm Queensland time Postal address GPO Box 200 Brisbane Qld 4001 Fax (07) 3239 1124 Website qsuper.qld.gov.au ABN: 60 905 115 063 SFN: 2610 419 41 8683 03/08/2015 IB28 And so you know, this information is provided by QInvest Limited (ABN 35 063 511 580 AFSL and Australian Credit Licence Number 238274) which is ultimately owned by the QSuper Board (ABN 32 125 059 006) as trustee for the QSuper Fund (ABN 60 905 115 063). All products are issued by the QSuper Board as trustee for the QSuper Fund. When we say QSuper, we re talking about the QSuper Board, the QSuper Fund, QSuper Limited or QInvest Limited, unless the context we re using it in suggests otherwise. We ve put this information together as general information only so keep in mind that it doesn t take into account your personal objectives, financial situation or needs, it shouldn t be relied on as legal or taxation advice and doesn t take the place of this type of advice. What we say about law or proposals is based on our interpretation of the law or proposals at the time we printed this document. You should consider whether the product is appropriate for you by reading a copy of the product disclosure statement before making a decision you can do this by downloading a copy from our website at qsuper.qld.gov.au or call us on 1300 360 750. QSuper Board of Trustees 2015

Permanent Disability Benefit Guide 3 Your permanent disability insurance This guide explains what you need to do to make a claim for a permanent disability benefit if you ve suffered an illness or injury that s left you unable to work. How do I apply? Like most insurance claims, there s paperwork you need to complete. Either you or your employer can apply for you to be assessed for a permanent disability benefit. Or we can start the process for you (if we re already paying you an income protection benefit and your medical details indicate you might not be able to return to your normal work). What we need from you or your employer is a detailed medical report from a medical practitioner. We need to let you know that you (or your employer) need to cover any costs for your doctor to provide this report. We ll pay for any subsequent medical information we need to assess your claim. To make a claim, please complete the Permanent Disability Benefit Application form that s included with this guide. You ll need to have a medical practitioner or specialist complete the doctor s statement at the back of this guide. We ve tried to make claiming as simple as possible, but please get in touch if you need any help completing the form. The completed documents you need to send us are: member s statement (completed by you) employer s statement (completed by your employer if you work for a non-queensland Government employer) doctor s statement (completed by a medical practitioner or specialist) copies of any other medical reports or certificates you might have about your injury or illness a certified copy of your proof of age (such as your birth certificate, passport or driver licence). Just so you know, a certified copy is a photocopy of an original document signed by a qualified certifier as a true copy of the original (you can find a list of these in our Proving your Identity factsheet on our website). How do you assess my claim? We understand you want your claim assessed as quickly as possible. We ll work with you to ensure this happens. Once we receive all the necessary paperwork from you, we ll allocate a claims manager and they ll contact you. As they manage your entire claim, they can talk you through the claims process. And they can answer any questions you might have about your claim. If you don t work for the Queensland Government, your insurance is provided by TAL Life Limited. If this is the case, we ll send your completed paperwork to them. Like us, they ll allocate a claims manager who ll get in touch with you and they ll manage your whole claim. We might get in touch with you to ask for additional information before we can make a decision about your claim. This could include: requesting further medical reports about your medical history or illness/injury (we cover any costs to get these reports) arranging for you to be seen by an independent medical specialist requesting additional financial information to help us work out your benefit. What if my claim isn t approved? If we don t approve your claim, we ll send you a statement of reasons explaining our decision. We let you know later in this guide what you can do if you re not happy with our decision. What if I m receiving an income protection benefit? An income protection benefit is payable if you re temporarily unable to work in your current job due to an illness or injury. If you become permanently disabled your income protection benefit stops. You can read more about this in our Income Protection Benefit Guide on our website, or call us and we ll send you a copy. What if I have a terminal medical condition? If you re diagnosed with a terminal medical condition that is likely to result in your death within 24 months, you may be able to access your super and your insurance benefit (if applicable). Just be aware though, if you aren t employed by the Queensland Government, accessing your super balance early due to a terminal medical condition could mean you are no longer eligible to claim your insurance benefit, which may be payable if you are diagnosed with a condition that is likely to result in your death within 12 months. The important terms section in the Accumulation Account Insurance Guide provides the definition(s) of having a terminal medical condition. You also should read our Terminal Medical Condition factsheet for more information, and to find out how accessing your super early may affect your eligibility to claim your insurance benefit. These documents are all available to download on our website at qsuper.qld.gov.au or call us and we ll send you a copy. What happens if I pass away? If you pass away, any insurance payout becomes part of your super benefit. Many people are surprised to know that your super doesn t form part of your estate. Instead it s distributed by the QSuper Board, generally to a dependant or legal personal representative. The Death Benefit Guide has more information about who can receive your super and any tax rules that apply. You can choose the person/s who ll receive your super when you pass away (as long as they re eligible) by completing and sending us a Making a Binding Death Benefit mination form available on our website, or call us and we ll send you a copy. If you have a Defined Benefit, or Police account, there might also be a benefit that s payable to your dependent children if you pass away. If you ve received a lump sum insurance benefit and you pass away from the same condition within 12 months of receiving it, there might also be a benefit payable to your dependent children.

4 Permanent Disability Benefit Guide How is my benefit calculated? Accumulation account If your super s in an Accumulation account with us, your death and TPD cover is provided in units, with each unit being worth a certain amount of cover. The value and cost of each unit varies with age. Between ages 65-69, you re only eligible for death cover. If you re a police officer 1, your death and TPD cover ends once you re 60. So your cover is calculated as the number of units multiplied by its value. For example, David is 36, works for Queensland Health and makes a standard contribution to his super, meaning he automatically gets four units of cover. The value of each unit is $125,000 so the amount of cover he has is $500,000. The benefit we pay if your claim is approved includes the insured amount as well as the balance of your Accumulation account when you make a claim. Of course, the payment of any additional cover you might have is subject to the pre-existing condition exclusion period. Defined Benefit account If your super s in a Defined Benefit account, and you re under 55, there are two parts to your payment: your current accrued benefits including any extra money you have in an Accumulation account your insurance benefit (this is your prospective benefit, which means the amount your Defined Benefit account would have grown if you d stayed a member up to age 55.) If you re working part-time, we ll adjust the prospective benefit we mentioned above to reflect this. If you re 55 or over, we ll pay your current accrued benefits only. You should know that you might be entitled to extra benefits if you have additional death and disability cover. The age limit for additional disability cover is 65. Additional death-only cover stops once you re 70. Proportional benefits If you aren t employed by the Queensland Government or a related entity and we ve received employer contributions for you and you have standard insurance, there might be a proportional benefit available within the five year pre-existing exclusion period. If you were at work on 16 December 2013, the pre-existing exclusion period reduced to a maximum of five years for your existing level of standard insurance cover and additional insurance cover. As we show in the table below, proportional benefits might be payable if your disability is 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% Percentage of standard insurance benefit 10% x amount insured + 2.5% x amount insured for each full month of continuous cover after 2 years You can check how much insurance cover you have by: logging in to Member Online (you ll first need to register for Member Online if you haven t already) reading your latest annual statement checking your QSuper welcome letter calling us on 1300 360 750. Pre-existing medical conditions A pre-existing medical condition is essentially a medical condition that you had before your cover started. If you commenced work on or after 16 December 2013 for the Queensland Government or a related entity employer, there s no pre-existing condition exclusion period for your standard cover (so we ll pay your benefit even if you had the condition before your cover started). However, if you were at work prior to 16 December 2013 a pre-existing exclusion period may apply. For all additional units of cover, there s a pre-existing exclusion period which depends on your date of disability. If you re not working for the Queensland Government or a related entity employer, there s a five year pre-existing exclusion period. However, you might be able to claim proportional benefits during the five year pre-existing exclusion period, which we explain now. 1 Different insurance arrangements apply to police officers.

Permanent Disability Benefit Guide 5 How is my benefit paid? What are my lump sum payment options? 1. Leave your benefit in an Accumulation account You can leave your money with us in an Accumulation account (and add other money to your account such as voluntary contributions or rollovers from other super funds). That way you ll continue to enjoy all the great benefits of being a QSuper member including low fees, solid returns and personalised service. This account offers a whole range of investment options, so we ve got something to suit your risk appetite and the level of involvement you re looking for. Of course, a number of factors (including your investment choices) will affect your account balance. You can make withdrawals from your super when you need to, just remember you need to withdraw a minimum of $2,000. You can read more about this in the Accumulation Account Guide on our website, or call us and we ll send you a copy. 2. Open an Income account Our award-winning 1 Income account gives you a flexible and tax-effective way to receive regular income payments from your super in retirement. You just need an opening balance of $30,000 to start an Income account. You can choose how much money you want to receive, although annual minimum limits apply. You can also withdraw lump sums if you need extra cash for any reason. So you know, you can t invest extra money into the account after the initial deposit, but you can open more than one Income account and receive separate incomes from each. Read more about our Income account in the Income Account Guide on our website, or give us a call. 3. Cash in your benefit You can take your benefit as cash but you might have to pay tax on some of your benefit. You can find out more by reading the Tax Explanation factsheet on our website. 4. Roll over to another complying super fund You can roll over part or all of your super into another complying super fund but first compare our low fees, solid returns and personalised service to what s offered by other funds. How is this benefit calculated? The PPD benefit is equal to your current accrued benefit. It s made up of: an unrestricted non-preserved amount (this is the cashable amount) and/or a preserved amount (the amount that s locked away until you permanently retire from the workforce and reach your preservation age). You can access your cashable amount at any time. You can check your annual statement to see what this amount is. We pay you this benefit as a lump sum payment. So you know, this is payable regardless of any pre-existing medical conditions. The rest of your benefit is preserved until you permanently retire from the workforce and reach your preservation age. You need to keep your benefit in an account with us or another complying super fund (make sure you first compare our low fees, solid returns and personalised service to what s offered by other funds). You can read more about this benefit in the Defined Benefit Account Guide on our website, or call us and we ll send you a copy. Your privacy We take the privacy of your information seriously. If you d like to know more about our individual privacy policies, download QSuper s Your Privacy factsheet on our website at qsuper.qld.gov.au, or download TAL s privacy policy at tal.com.au/privacy-policy Permanent and Partial Disability (Defined Benefit account holders only) If your illness or injury has left you permanently unfit or unable to do your usual job (but not totally and permanently disabled), you might be eligible to receive a permanent and partial disability (PPD) benefit. 1 Chant West Super Fund Awards 2015.

6 Permanent Disability Benefit Guide Review and appeal process What if I m not happy with the decision? We understand not everyone will be satisfied with decisions QSuper and TAL make on claims. You re welcome to lodge an appeal for review by QSuper and/or TAL. Send your appeal in writing to: Legal Review Unit, QSuper Group Life Insurance, GPO Box 200, Brisbane Qld 4001. You need to cover any costs to obtain medical reports you need or want to support your appeal. If you re still not satisfied with the decision after our review, you can lodge a complaint with the Superannuation Complaints Tribunal (SCT). This needs to be done within two years of the date we made the original decision. What is the Superannuation Complaints Tribunal (SCT)? The SCT is an independent tribunal set up by the Australian Government to review complaints relating to decisions made by super funds. It s designed to be an economical, fair, and quick review process. Just remember you need to use our internal appeal process before going to the SCT. If you re not happy with the decision or we haven t contacted you within 90 days of lodging your appeal, call the SCT on 1300 884 114. They ll let you know if they can deal with your complaint and if they can, the information you ll need to give them. You can visit the SCT website at sct.gov.au for further information. Need more information? To find new ways to get more out of your super, have a play around with the tools and calculators on our website at qsuper.qld.gov.au. You can experiment with as many different inputs and scenarios as you like. And we re always here to help on the phone too. Just call us on 1300 360 750 to get in touch.

QSuper Form Please complete in block letters, in blue or black ink. 1 Permanent Disability Benefit Application Member ment Who needs to complete this form? You need to complete this part of the claim form to apply for a permanent disability benefit. We need detailed information about your job and your illness/injury to be able to assess your claim. Make sure you provide your current medical practitioner s contact details in case we need to get in touch with them for more information. And get in touch if you need any help completing the form. 1 Personal details 2 Details of your illness or injury Client number You can find your client number on your annual statement or by logging in to Member Online. Title Surname Given names Please enclose copies of any medical information you have, such as WorkCover records or Veterans Affairs assessments that might be useful when we consider your claim. of your illness or injury (please provide a detailed description) What caused your illness or injury? Previous name 1 (if we know you by another name) Date of birth (dd/mm/yyyy) Home phone number Are you receiving, or willing to receive, appropriate medical care as recommended by your treating medical practitioners? If no, please provide reasons Mobile phone number Email address Work phone number When did you first start to experience signs or symptoms? Date (dd/mm/yyyy) Residential address When was your illness first diagnosed or when were you injured? Date (dd/mm/yyyy) Postal address Employment status As above When did you first visit a doctor about your illness or injury? Date (dd/mm/yyyy) If you ve suffered from a similar illness or injury previously, please tell us about it below. Please describe the illness or injury, when you were diagnosed, the doctor you saw and any treatment you had. Self-employed Full-time Part-time Casual Other (including unemployed) If other or unemployed, please provide details below: Doctor s name Doctor s address 1 If you ve changed your name you ll need to give us certified copies of either a marriage certificate or other legal change of name document.

2 Permanent Disability Benefit Application Member ment Doctor s phone number Please tell us about the treatment you ve had for this illness or injury Please tell us your capacity to do the following activities: Can you dress yourself? (e.g. putting on and taking off clothes) Please describe the help you need and any limitations. Describe the treatment Date started (dd/mm/yyyy) How often Can you bathe yourself? (e.g. washing and showering) Please describe the help you need and any limitations. Are you currently participating in treatment? How effective has the treatment been? Toileting (e.g. can you use the toilet, including getting on and off?) Please describe the help you need and any limitations. Have you been able to work in any job, whether full-time or part-time, paid or unpaid, since your illness/injury? If so, please give details. Are you mobile? (e.g. walking, getting in and out of a chair or bed) Please describe the help you need and any limitations. Do you plan to return to work? If no, please provide details Can you feed yourself? (e.g. getting food from a plate to your mouth) Please describe the help you need and any limitations. Can you do housework? (e.g. cooking and cleaning) Please describe the help you need and any limitations. If yes, when do you think you ll return to work? (dd/mm/yyyy) Do you need rehab assistance? (please specify below) Are you able to drive? If no, please provide details Have you talked to your doctor about a return to work program? (please describe below) Do you take care of children or other dependants? What was the outcome of this discussion?

Permanent Disability Benefit Application Member ment 3 3 Medical practitioner details Please provide details of your current treating medical practitioner(s) and/or specialist(s). Practitioner 1 Practitioner 4 Phone number Phone number Postal address Postal address Specialty Specialty Date first contacted (dd/mm/yyyy) Date last contacted (dd/mm/yyyy) Date first contacted (dd/mm/yyyy) Date last contacted (dd/mm/yyyy) Practitioner 2 Practitioner 5 Phone number Phone number Postal address Postal address Specialty Specialty Date first contacted (dd/mm/yyyy) Date last contacted (dd/mm/yyyy) Date first contacted (dd/mm/yyyy) Date last contacted (dd/mm/yyyy) Practitioner 3 If you ve consulted other doctors, specialists or health professionals about your illness or injury, please provide their details separately and attach it to your application form. Phone number Postal address Specialty Date first contacted (dd/mm/yyyy) Date last contacted (dd/mm/yyyy)

4 Permanent Disability Benefit Application Member ment 4 Recreational activities 6 Job details and employment history Please describe your hobbies/interests/social activities Please describe your job in detail, including all your duties and responsibilities. (Please attach your position description and a copy of your resume.) Does your condition affect your ability to do these activities? If yes, please describe how you re affected. If your role involves manual handing duties (lifting, carrying, pushing, pulling) please provide details of these specific duties below. 5 Other entitlement details Have you claimed a permanent disability benefit in the past? Date paid (or date of application) Amount of benefit (and who paid the benefit) $ Have you claimed (or do you plan to claim) other insurance for this illness/injury? If yes, please provide details. What was your base salary before your illness/injury? $ Hourly Fortnightly Monthly What duties are/were you able to do? What duties are/were you prevented from doing? Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Have you claimed (or do you plan to claim) Department of Human Services entitlements for this illness or injury? Start date (dd/mm/yyyy) End date (dd/mm/yyyy) What educational qualifications, degrees, certificates (including First Aid and OHS) do you hold? Please include the year achieved when providing details below. Secondary school (e.g. year 10, year 12) Have you claimed (or do you plan to claim) a benefit from WorkCover for this illness or injury? Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Tertiary (university or technical college) Post-graduate Claims manager TAFE Phone number Claim no. Other If you re claiming any other insurance or entitlements, please provide your: Case manager s name Describe your specific work skills (for example, management/ supervision, retail, computer skills)? Case manager s phone number Claim reference number Insurance company

Permanent Disability Benefit Application Member ment 5 Please provide details of previous jobs (approximate dates are fine) Position Employer When did you first stop working because of your illness or injury? Date (dd/mm/yyyy) Start date (dd/mm/yyyy) End date (dd/mm/yyyy) If you ve terminated your employment, was it due to this illness or injury? Please describe all of your duties and responsibilities If yes, please tell us the exact date this happened and the name of your employer. Date (dd/mm/yyyy) Position Employer of employer Start date (dd/mm/yyyy) End date (dd/mm/yyyy) Please describe all of your duties and responsibilities Please complete if you re self-employed What were your income and expenses for the last 12 months (pre-disability)? Gross income from occupation $ Expenses $ Position Start date (dd/mm/yyyy) Employer End date (dd/mm/yyyy) What were your income and expenses for the last 24 months (pre-disability)? Gross income from occupation $ Expenses $ Please describe all of your duties and responsibilities Are you still employed? Do you/have you managed or supervised staff? If yes, how many? Your employer District/school/region (only if you work for the Queensland Government and it applies to you) Position/title Payroll number Manager s name Manager s phone number

6 Permanent Disability Benefit Application Member ment 7 Authority to access and release 8 medical details Declaration and authorisation I consent to QSuper (and its agents and advisers) to contact medical practitioners I ve seen and to contact other organisations who might have medical or other information that s relevant to my claim. I understand these organisations could include: WorkCover, Department of Human Services, Q-COMP, Department of Veterans Affairs, insurance companies and my employer. I authorise those medical practitioners and other organisations to release such details (which may include sensitive or health information) to QSuper, its agents and advisers as may be requested. I consent to QSuper releasing medical and other information (which may include sensitive or health information) to my employer, WorkCover, medical and allied health advisers, and agents who could be asked to provide reports and/or opinions about my claim. I understand and agree that if I don t sign this authority, or if I don t give information requested by QSuper or its representatives, QSuper mightn t be able to assess my claim. I consent to the release of my personal and medical information from, and to the following parties for the purpose of investigating and assessing my claim: 1. Workers compensation 2. CTP insurer 3. Federal and Government including the Department of Human Services and the Department of Veterans Affairs 4. My employer (only with my written consent) 5. My accountant 6. My doctors, specialist/s and their agents 7. QSuper 8. QSuper s appointed insurer TAL Life Ltd (ABN 70 050 109 450) 9. QSuper s appointed assessor which could be located overseas in rth America or the European Union. Signature Date (dd/mm/yyyy) I confirm the information included in this application is true and correct, and I haven t withheld any information that s relevant to this claim. I agree to provide all medical information that s requested and to undertake any medical or occupational assessments that QSuper considers appropriate. Signature Date (dd/mm/yyyy) Checklist Make sure you use this checklist to check you ve fully completed the Permanent Disability Benefit Application form and you have all the supporting documents ready to send us. I ve provided all the relevant information in section 1. I ve provided details on my condition in section 2 and attached copies of any medical evidence I already have on my condition (and any other relevant information). I ve provided details of my recent medical practitioners in section 3. If I m claiming any other entitlements, I ve provided details in section 5. I ve completed my job details and employment history. I ve completed and signed the medical authority. I ve signed the QSuper declaration in section 8. A copy of this content and your authorisation is considered the same as an original. Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone 1300 360 750 (+617 3239 1004 if overseas) Monday Friday 8.30am to 5.00pm Queensland time Postal address GPO Box 200 Brisbane Qld 4001 Fax (07) 3239 1124 Website qsuper.qld.gov.au ABN: 60 905 115 063 SFN: 2610 419 41 8683 03/08/2015 IB28 Just quickly, we need to let you know that this form is issued by the QSuper Board (ABN 32 125 059 006). All QSuper products are issued by the QSuper Board as trustee for the QSuper Fund (ABN 60 905 115 063). We take the privacy of your personal information very seriously. We re collecting this information to administer your superannuation account and are authorised to do this under the Superannuation ( Public Sector) Act 1990. We may pass your information on to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. We may also disclose this information to third parties if we need to, if you ve given consent to the disclosure, or if we re required to by law. If you want to know more about our privacy policy, you can download QSuper s Your Privacy factsheet from our website or call us on 1300 360 750 and ask for a copy. We ve put this information together as general information only so keep in mind that it doesn t take into account your personal objectives, financial situation, or needs, shouldn t be relied on as legal or taxation advice, and doesn t take the place of this type of advice. Before you make any decision to acquire a product, or to keep hold of one you already have you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy. QSuper Board of Trustees 2015

QSuper Form Please complete in block letters, in blue or black ink. 1 Permanent Disability Benefit Application Employer s ment (n-queensland Government employers) Who needs to complete this form? This part of the claim form needs to be completed by your non-queensland Government employer (HR or payroll office staff). 1 Employee s details 3 Salary details Title Given names Surname Date of birth (dd/mm/yyyy) Payroll number Position/title What was your employee s basic monthly salary (gross) before they stopped working? $ What was your employee s package monthly salary (gross) before they stopped working? $ per month per month Please provide details of the salary package below. Work phone number Date employee joined this company (dd/mm/yyyy) When did you start contributing to QSuper for this employee? (dd/mm/yyyy) 2 Employer details of employer Work phone number Mobile phone number Email address Address of head office Employee s work address Same as above

2 Permanent Disability Benefit Application Employer s ment 4 Employment status 5 Return to work What is the employee s employment status? Self-employed Permanent part-time Permanent full-time Casual Other including unemployed (please tell us below) Please tell us the employee s present employment status (and include a date if it applies) Still employed Resigned Terminated (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) Are there any workplace accommodations that could be made to assist the employee to return to work, such as modified hours, light duties, modified duties, or an alternate role? Please provide details of what could be supported below. Modified duties Modified hours Light duties Alternate role Are there any specific requirements to start a graduated return to work? If yes, please specify. Redundancy Disability leave Retirement Other (specify below) (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) (dd/mm/yyyy) Is there a return-to-work coordinator to help the employee with an appropriate return-to-work plan? If so, please provide contact details. Work phone number Mobile phone number How many hours did the employee work on average before their injury or illness? hours per week Email address What date did the employee stop all duties? (dd/mm/yyyy) So you know this date isn t necessarily the same as the date their employment was terminated. Did the employee work in a reduced capacity or in a different role before they stopped working? If yes, please provide details below. What was the reason the employee stopped work?

Permanent Disability Benefit Application Employer s ment 3 6 Physical work environment details Does the employee s job require them to work in any of the following conditions? Please tick the relevant option. Outside If yes, percentage of time % If the employee s job involves manual handling, please describe the types of items they might lift/push/pull/carry, the physical demand associated with these tasks and how often they perform these tasks? Lift (floor to waist) In extreme cold and/or heat Lift (knee to shoulder) If yes, percentage of time % In a damp or humid environment If yes, percentage of time % Lift (waist to overhead) Push/pull In a noisy environment Carry If yes, percentage of time % In a dusty or unventilated environment How long is the employee required to do the following before they can change their position or the activity? If yes, percentage of time % Around toxic fumes If yes, percentage of time % During the employee s normal routine, what percentage of time does the job require the employee to lift or carry the following weights? 23kg or over Never 1-25% 26-50% 51-75% 76-100% 9 to 22kg Never 1-25% 26-50% 51-75% 76-100% Under 9kg Never 1-25% 26-50% 51-75% 76-100% During the employee s normal routine, what percentage of time does their job involve the following activities? Walking Never 1-25% 26-50% 51-75% 76-100% Walking on uneven ground Never 1-25% 26-50% 51-75% 76-100% Sitting at one time 0-30 mins Standing at one time 0-30 mins Driving at one time 0-30 mins During the average day, what s the average number of hours the employee spends in the following positions or activities? Sitting 0-2 hours Standng Driving 0-2 hours 0-2 hours 31-50 mins 31-50 mins 31-50 mins 2-4 hours 2-4 hours 2-4 hours 51-90 mins 51-90 mins 51-90 mins 4-6 hours 4-6 hours 4-6 hours Over 90 mins Over 90 mins Over 90 mins 6-8 hours 6-8 hours 6-8 hours What percentage of the employee s time is spent on the following activities? Talking Writing % % Driving Never 1-25% 26-50% 51-75% 76-100% Reaching above shoulders Never 1-25% 26-50% 51-75% 76-100% Reaching below shoulder height Never 1-25% 26-50% 51-75% 76-100% Bending or crouching Never 1-25% 26-50% 51-75% 76-100% Kneeling or crawling Never 1-25% 26-50% 51-75% 76-100% Supervising other people Please describe below any other aspects or demands of the employee s work duties that aren t described in the above categories. Are you aware of any other claims being made by or for the employee? If yes, please provide details. %

4 Permanent Disability Benefit Application Employer s ment 7 Supporting documents Please attach the following documents with your completed form (and 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 to assist in the assessment of the employee s claim. 8 Declaration I declare the information included in this form is true and correct, and I haven t withheld any relevant information. Signature Date (dd/mm/yyyy) Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone 1300 360 750 (+617 3239 1004 if overseas) Monday Friday 8.30am to 5.00pm Queensland time Postal address GPO Box 200 Brisbane Qld 4001 Fax (07) 3239 1124 Website qsuper.qld.gov.au ABN: 60 905 115 063 SFN: 2610 419 41 8683 03/08/2015 IB28 Just quickly, we need to let you know that this form is issued by the QSuper Board (ABN 32 125 059 006). All QSuper products are issued by the QSuper Board as trustee for the QSuper Fund (ABN 60 905 115 063). We take the privacy of your personal information very seriously. We re collecting this information to administer your superannuation account and are authorised to do this under the Superannuation ( Public Sector) Act 1990. We may pass your information on to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. We may also disclose this information to third parties if we need to, if you ve given consent to the disclosure, or if we re required to by law. If you want to know more about our privacy policy, you can download QSuper s Your Privacy factsheet from our website or call us on 1300 360 750 and ask for a copy. We ve put this information together as general information only so keep in mind that it doesn t take into account your personal objectives, financial situation, or needs, shouldn t be relied on as legal or taxation advice, and doesn t take the place of this type of advice. Before you make any decision to acquire a product, or to keep hold of one you already have you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy. QSuper Board of Trustees 2015

QSuper Form Please complete in block letters, in blue or black ink. 1 Permanent Disability Benefit Application Doctor s ment Who needs to complete this form? Your medical practitioner needs to complete this form. We need detailed information from them about your illness/injury before we can pay you a permanent disability benefit. Remember that you re responsible for covering any costs your doctor charges to complete this form. 1 Claimant s details 2 Treatment history (medical practitioner completing this form) Title Given names Surname Speciality Work phone number Date of birth (dd/mm/yyyy) Height (cm) Weight (kg) Practice Email address Postal address 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? 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. What was the diagnosis?

2 Permanent Disability Benefit Application Doctor s ment Has the claimant ever experienced these, or similar symptoms, previously? Please indicate the primary diagnosis affecting your patient s functional capacity. If yes, from when? (dd/mm/yyyy) If yes, please explain. Please detail your objective findings in regard to the diagnosis that was made. Please outline any other diagnoses that are affecting your patient s functional capacity (if applicable). What active treatment (including medication and dosage) has the claimant received from yourself and other practitioners since this condition was diagnosed? Please outline the objective findings to support the additional diagnoses noted above. What tests or investigations have been done to date and what were the results of these tests? Did the claimant see any other doctors prior to their first consultation with you? How often are you seeing the claimant at this time? If yes, please provide the contact details of the doctor first seen and the date of this consultation. Practice Have the claimant s symptoms changed in frequency or severity? If yes, please describe how. Postal address Has the claimant been referred to a consultant or specialist? Work phone number If yes, date referred: Date (dd/mm/yyyy) First appointment Date of consultation (dd/mm/yyyy) If yes, please provide contact details for the consultant or specialist. When was the diagnosis made? (dd/mm/yyyy) Speciality Work phone number Practice Postal address

Permanent Disability Benefit Application Doctor s ment 3 3 Claimant s capacity to work What is your understanding of the claimant s job and their duties? 4 Declaration Speciality Is the claimant working at present?, part-time, full-time If yes, when did the claimant return to work? Signature Date (dd/mm/yyyy) Is the claimant currently performing their usual work duties? If no, what duties is the claimant performing? How many hours is the claimant currently working each week? hours per week Please outline the medically-supported restrictions and/or limitations that would need to be considered for the claimant to return to work. In regard to the restrictions and limitations you ve noted above, if there was a way these could be accommodated in the claimant s workplace (or in a different role/job), are there any medical barriers to them pursuing such work opportunities now or in the future? If yes, please outline the specific medical barriers and if these are considered temporary or permanent, providing relevant details.

4 Permanent Disability Benefit Application Doctor s ment Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane Telephone 1300 360 750 (+617 3239 1004 if overseas) Monday Friday 8.30am to 5.00pm Queensland time Postal address GPO Box 200 Brisbane Qld 4001 Fax (07) 3239 1124 Website qsuper.qld.gov.au ABN: 60 905 115 063 SFN: 2610 419 41 8683 03/08/2015 IB28 Just quickly, we need to let you know that this form is issued by the QSuper Board (ABN 32 125 059 006). All QSuper products are issued by the QSuper Board as trustee for the QSuper Fund (ABN 60 905 115 063). We take the privacy of your personal information very seriously. We re collecting this information to administer your superannuation account and are authorised to do this under the Superannuation ( Public Sector) Act 1990. We may pass your information on to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies. We may also disclose this information to third parties if we need to, if you ve given consent to the disclosure, or if we re required to by law. If you want to know more about our privacy policy, you can download QSuper s Your Privacy factsheet from our website or call us on 1300 360 750 and ask for a copy. We ve put this information together as general information only so keep in mind that it doesn t take into account your personal objectives, financial situation, or needs, shouldn t be relied on as legal or taxation advice, and doesn t take the place of this type of advice. Before you make any decision to acquire a product, or to keep hold of one you already have you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy. QSuper Board of Trustees 2015 20150803IB28