Member Details form Member Income Protection Insurance Matching Form

Member Details form Member Income Protection Insurance Matching Form w Complete this form if you want LUCRF Super to match the amount of your existing Income Protection insurance cover held with another fund. IMPORTANT: Do not cancel your existing insurance cover with another fund until you have received confirmation in writing that your request has been accepted by the Trustee of LUCRF Super. When to use this form Use this form if you wish to apply for LUCRF Super to match the amount of any existing Income Protection insurance cover held in another fund. You can only apply to match the amount of your insurance cover if: 1. You are applying to match the amount of Income Protection cover and you are aged between 16 and 60 years 2. You have not made or you are not entitled to make a claim in relation to your cover held in the other fund. Your insurance cover is held in another superannuation fund. We will not match the amount of any retail cover held outside of superannuation 4. Your cover held in the other fund was granted to you on standard terms e.g. there is no loading or exclusions attached to the cover Important If your application to match the amount of cover held in another fund is accepted by LUCRF Super, your new insurance cover will be subject to LUCRF Super s terms and conditions. These may be different to the terms and conditions you have with your other policy(ies), you should therefore ensure you are satisfied with LUCRF Super s terms and conditions before you cancel any other policy(ies) you may have. If approved, LUCRF Super will provide you with a sufficient amount of insurance which matches the amount of your cover held in the other fund. The matched cover will be added to any existing Income Protection cover you currently hold with LUCRF Super subject to the combined benefit amount not exceeding $1,600 per week. Note: Insurance eligibility is at the discretion of the insurer. 5. You wish to match cover up to a maximum of $1,400 per week 6. The waiting period for cover in the old fund is 90 days or less 7. You agree to validly cancel the cover held in the other fund once you receive confirmation that the Trustee of LUCRF Super has accepted your request to match the amount of cover within LUCRF Super 8. A maximum benefit period of two years will apply to the matched cover 9. You have an employer making contributions into your LUCRF Super account 10. Your total sum insured does not exceed $1,600 per week. Issued by L.U.C.R.F Pty Ltd ABN 18 005 502 090 AFSL 258481 as Trustee for Labour Union Co-operative Retirement Fund ABN 26 82 680 88 (LUCRF Super), 1 February 2014. LUCRF0525_0214 Member Income Protection Insurance Matching Form Page 1 of 5

Please complete all relevant sections using CAPITAL LETTERS and a BLACK or BLUE pen. Step 1 Your details LUCRF Super member number (if known) Date of birth (dd/mm/yyyy) / / Please cross [X] the appropriate box: Mr Mrs Miss Ms Other (please specify) Surname First names Residential/Street address (compulsory) Unit / Street number Street name Suburb / City / Town State / Territory Postcode Postal address if different to residential Unit / Street / PO Box number Street name Suburb / City / Town State / Territory Postcode Please send all correspondence to (please cross [X]): Residential address Postal address Contact numbers Home Work Mobile Email address Please read our Personal Information Collection Statement at lucrf.com.au/privacy Member Income Protection Insurance Matching Form Page 2 of 5

Step 2 Your existing insurance cover Complete this section to provide details of your existing insurance cover with your other fund, you will also need to provide written proof (see Documents needed on page ) Insurance cover held with the other fund Name of other Fund/Plan Your member number with the other Fund/Plan I confirm that I have the following amount of income protection cover: Value of cover per week Date cover started (dd/mm/yyyy) $ / / Waiting period Benefit period Is your existing insurance cover subject to: Please cross [X] boxes for Yes or No answers 1. A premium loading? YES NO 2. An exclusion? YES NO. A restriction? YES NO 4. A pre-existing condition? YES NO 5. Any other limitation of any sort? YES NO Please note that LUCRF Super will not automatically match the amount of cover you have in your other fund, if you answered YES to any of the boxes for the questions above. However you can still apply by completing a Member Income Protection Form. To obtain a copy, please call LUCRF Super on 100 10 780 or download a copy from lucrf.com.au DID YOU ANSWER YES TO ANYTHING? Documents needed When applying to have your insurance cover matched by LUCRF Super, you must provide the following documents with this form: Most recent Member Super Statement Attach a copy of your most recent statement from your other fund, which sets out the type and level of cover you have with this fund. If your insurance cover has changed since the date of your most recent statement, you will need to provide evidence of the current type and level of cover held with your other fund. Special Acceptance Terms If applicable, attach a copy of any special acceptance terms you agreed to with your other fund (e.g. if your cover is subject to a restriction, exclusion or limitation. You need to provide LUCRF Super with information concerning any special acceptance terms). The waiting period that applies to the transferred cover will be: 0 days if it was 0 days or less under the previous cover 60 days if it was greater than 0 days and up to 60 days under the previous cover 90 days if it was greater than 60 days and up to 90 days under the previous cover. Member Income Protection Insurance Matching Form Page of 5

Step Your work category To ensure you receive the correct insurance cover we need to identify the work category that best represents the type of work you do. Please cross [X]: What is the name of your current employer? What is your main occupation? If yes, please specify your occupation(s) Are you engaged in any other occupations? YES NO 1. Do you spend at least 80% of your total working time in an office or similar environment performing administrative, clerical or sedentary type duties? (This includes the total amount of time spent in all occupations as advised above) YES NO If yes, proceed to questions 2 and. If no, proceed to questions 4 and 5. Only complete questions 2 & if you answered yes to question 1. 2. Do you have a university degree qualification relevant to the field of your main occupation or, are you an executive or senior managerial white-collar worker and not self-employed or are you a member of a professional institute? YES NO. Is your current annual salary package (including superannuation guarantee contribution) in excess of $150,000? YES NO Only complete questions 4 & 5 if you answered no to question 1. 4. Do you have a recognised trade qualification relating to you occupation or, does your occupation require you to perform light manual work or, are you a supervisor of blue collar workers and your duties include up to 10% of light manual work? (e.g. an electrician, mechanic, printer, signwriter, greengrocer, carpenter, storeman, poultry processing employee, plumber etc? YES NO 5. Are you a skilled or semi-skilled worker whose duties include heavy manual work or are you required to operate heavy machinery (e.g. qualified wall/floor tiler, glazier, bulldozer driver, forklift driver)? YES NO If you answer yes to questions 1, 2 and you will be classified as Professional. If you answer yes to question 1 and no to either question 2 or, you will be classified as White Collar. If you answer no to questions 1 and 5 and yes to question 4, you will be classified as Light Blue. If you answer no to questions 1 and 4 and yes to question 5, you will be classified as Heavy Blue. If you answer no to questions 1, 4 and 5, income protection cover will be declined. Step 4 Health questions You need to complete all of the health questions below to apply to match your insurance cover through LUCRF Super. IMPORTANT: Your declaration will be checked at the time you make a claim. If you do not answer all of the questions truthfully and accurately, this may result in any insurance claim being reduced or denied. Please cross [X] boxes for Yes or No answers 1. Are you restricted, due to injury or illness from carrying out all the usual duties of your current occupation on a full time basis of at least 0 hours per week (even if you are not currently working on a full-time basis)? YES NO 2. Have you been paid or are you currently in receipt of, or intending to, or entitled to, claim any form of sickness, accident or disability benefit(s) from any source? YES NO. a. I have taken more than a total of 7 consecutive days off work over the past 12 months due to illness or injury (other than for cold or flu) YES NO b. I have been diagnosed with any illness that reduces my life expectancy to less than 12 months from today YES NO If you answered YES to any of the statements in Section 4, you can not proceed with this application. You will need to apply for cover by completing the OnePath Personal Statement, which is available online at lucrf.com.au Please note that LUCRF Super will not automatically match the amount of cover you have in your other fund, if you answered YES to any of the boxes for the questions above. However you can still apply by completing a Member Income Protection Form. To obtain a copy, please call LUCRF Super on 100 10 780 or download a copy from lucrf.com.au DID YOU ANSWER YES TO ANYTHING? Member Income Protection Insurance Matching Form Page 4 of 5

Step 5 Sign and date this form Duty of disclosure You have a duty, under the Insurance Contracts Act 1984 to disclose to the Insurer every matter that you know, or could reasonably be expected to know, that is relevant to the Insurer s decision whether to accept the risk of the insurance, and if so, on what terms. Your duty, however, does not require disclosure of a matter: That diminishes the risk to be undertaken by the Insurer That is common knowledge That your Insurer knows or, in the ordinary course of his/her business, ought to know As to which compliance with your duty of disclosure is waived by the Insurer. Non-disclosure If you fail to comply with your duty of disclosure and the Insurer would not have entered into the contract on any terms if the failure had not occurred, the Insurer may void the contract within years of having entered into it. If your non-disclosure is fraudulent, the Insurer may void the contract at any time. An Insurer who is entitled to void a contract of life insurance may, within years of entering into it, elect not to void it but to reduce the sum you have been insured for in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to the Insurer. I declare that: I understand my duty of disclosure and the effect of non-disclosure under the Insurance Contracts Act 1984. I have answered all questions in this application truthfully and correctly (to the best of my knowledge), and have disclosed everything I know that could affect OnePath Life s decision to accept my application. I understand that I must advise OnePath Life of any changes in my health from now until I am notified in writing that my application has been accepted. I understand that insurance cover through LUCRF Super will be provided to me on the terms contained in LUCRF s insurance policy as changed from time to time. I have read and understood the Super Member Guide (Product Disclosure Statement) and the associated reference material as currently available at lucrf.com.au/forms-and-publications I consent to the collection, use and disclosure of my personal information in accordance with the OnePath Life Privacy Statement, available at onepath.com.au/privacy-policy or by calling 02 924 8111, and the LUCRF Super Personal Information Collection Statement and the Privacy Policy available at lucrf.com.au/privacy or by calling 100 10 780. I understand that if my application is accepted I will be notified in writing and my insurance cover will change in accordance with the direction I have made in this form. The change will be effective from the date LUCRF s insurer accepts this application and provided my member account has adequate funds to meet the premium payable. Sign (member signature) 7 Date (dd/mm/yyyy) / / Checklist Before you send the form to us, make sure you have: Answered your existing insurance and health questions honestly Attached a copy of your most recent Member Super statement from your other fund Attached a copy of any special acceptance terms agreed with other fund (if applicable) Completed and attached a Member Income Protection Form (if required) Signed and dated this form Send this form to: LUCRF Super PO Box 211 North Melbourne VIC 051 Fax (0) 926 6907 Email mypartner@lucrf.com.au If you need any help completing this form, please call us on 100 10 780 or email mypartner@lucrf.com.au Member Income Protection Insurance Matching Form Page 5 of 5