Life Events Application Form
Life Events Application Form When a specific life event occurs, you can increase your Death only cover or Death and TPD cover without having to provide any information about your health or answer lengthy questionnaires. It is important you read the important notes at the end of this form and understand your duty of disclosure. This form can be used by all members of a division of Emplus Super 1. YOUR PERSONAL DETAILS Full Name: Address: Date Of Birth: Member Number: Work Phone: Home Phone: Mobile Phone: Email: I authorise OnePath Life’s underwriting service representative to contact me by phone if further information is required. I can be contacted during the following times: Monday Tuesday Beteen Wednesday am/pm Thursday and Friday Any business day Mobile Phone am/pm Please tick your preferred contact method: Home Phone Work Phone Are you a permanent resident of Australia? Yes No 2. ELIGIBLITY If you answered YES to any of these three questions, you cannot proceed with this application to obtain additional cover. At the time of making this application, have you lodged or are you entitled to make a claim in relation to any life insurance policy? Have you ever had an application for insurance declined by OnePath Life? At the time of making this application, are you 55 years or older? If you answered YES to either of these two questions, you cannot proceed with this application to obtain additional cover. You can still apply for extra cover by completing the OnePath Group Risk Insurance - Personal Statement available from the forms section at www.Emplus.com.au/forms or contact Emplus Super on 1800 336 911. P PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E [email protected] | W www.emplus.com.au Emplus ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 1 of 3 3. SPECIFIC LIFE EVENT Full Name: Please select the life event you are applying under to increase your cover: Life Event Date of Event Documentation Required Birth or adoption of your child / / A copy of the birth certificate for your child or the adoption documentation. Getting married / / A copy of your Marriage Certificate. Your dependent child starting secondary school / / Taking out or increasing a mortgage on your principal place of residence by more than $100,000 / A copy of the birth certificate for your child or the adoption documentation, and a certified copy of the letter of admission from the secondary school your child will be attending. Written confirmation from your accredited mortgage provider(s)* of: • the amount and effective date of the mortgage, or • the amount of the mortgage immediately before the increase, the effective date of the increase and the current level of the increased mortgage. Attach a copy of the document(s) specified above that proves the event you’ve selected occurred in the past 90 days of us receiving your completed application. The document must be issued by a relevant government body (e.g. Registry of Births, Deaths and Marriages) or accredited mortgage provider*. / *Accredited mortgage provider means an Authorised Deposit-taking institution (as defined in the Banking Act 1959) or other reputable financial services business, program or trustee which provides mortgage loans as part of its ordinary business activities and is accredited with the Mortgage Industry association of Australia. 4. TYPE OF COVER I want additional: Death Only Cover OR Death and TPD Cover 5. MEMBER DECLARATION I declare that: • • • • • • • • I have read and carefully considered all the information in this Life Events Application Form, and all the answers provided in this form are true and complete (including those not in my own handwriting). I have read and understood the most recent version of Emplus Super’s Product Disclosure Statement(s) and/or Insurance Guide. I understand that if my application is accepted, insurance cover will be provided to me on the terms contained in the Policy as changed from time to time. I understand that the additional cover I have requested in this form will not become effective until my application is accepted in writing and provided my member account has adequate funds to meet the premium payable. I acknowledge that if I do not complete this form correctly or I do not sign and date this Declaration, my application will not be considered by OnePath Life any insurance cover I currently have will not be affected. I understand and accept that all the terms and conditions, including individual conditions, exclusions or restrictions, that currently apply to my existing cover will also apply to any additional cover. I understand my Duty of Disclosure and the remedies available to OnePath Life Ltd if I fail to comply with my Duty of Disclosure under the Insurance Contracts Act 1984, as explained in this form. I understand that my Duty of Disclosure continues after I have completed this application until I am notified in writing that my application has been accepted. I have read and understood the Privacy Statement of Emplus Super and OnePath Life’s privacy policy available at www.onepath.com.au/aboutOnePath/privacy-policy.aspx and consent to my personal information being collected and used in accordance with these statements. I understand that OnePath Life may not be able to process my application without this consent. Your Signature: Date: / / We are committed to respecting the privacy of the personal information you give us. Our formal Privacy Statement sets out how we do this. If you would like a copy of Emplus Super’s Privacy Statement, please let us know. We have published our Privacy Statement on our website at www.Emplus.com.au P PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E [email protected] | W www.emplus.com.au Emplus ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 2 of 3 IMPORTANT NOTES The amount of the increase will be: • • 1 unit if you currently hold unitised cover; or The lesser of 25% of your existing amount of cover or $200,000, if you currently hold fixed dollar cover. A specific life event is any of the following: 1. 2. 3. 4. You or your spouse giving birth to or adopting a child Getting married Your dependent child starting secondary school Taking out or increasing your mortgage on your principal place of residence by more than $100,000 To take up extra cover under this option: • • • • • • • you must not have lodged or be entitled to make a claim in relation to any life insurance policy this application must be received by us within 90 days of the specific life event occurring you must be aged less than 55 years when the specific life event occurs the specific life event must have occurred after your cover with Emplus Super commenced you must not have increased your cover under this option in the previous 12 months or on 3 previous occasions you cannot increase your cover because of your marriage more than once you must not have had a previous application for insurance declined by OnePath Life Important notice Insurance cover is provided by OnePath Life Limited (OnePath Life) (ABN 33 009 657 176 AFSL 238 341) and is subject to the terms and conditions of the insurance policy issued to Equity Trustees Limited (ABN 46 004 031 298) as Trustee of Emplus Superannuation Fund (ABN 18 838 658 991) by OnePath Life (the Policy), and as agreed with the Trustee and OnePath Life from time to time. You should read Emplus Super’s Product Disclosure Statement (PDS) and/or Insurance Guide for a summary of the terms and conditions of the Policy. You can download the PDS and Insurance Guide from www.Emplus.com.au/forms or contact Emplus Super on 1800 336 911 or 07 3899 7200 if you would like a copy of the Policy. Your application will be assessed by OnePath Life and Emplus Super will notify you of the outcome in writing. DUTY OF DISCLOSURE Before you(as an eligible person or insured member) become insured under a contract of insurance with the Insure or the Trustee enters into a contracrt of insurance with the Insurer, you, your employer and/or the Trustee have a duty under the Insurance Contracts Acts 1984 (Cth) to disclose to the Insurer every matter that you and/or the Trustee knows or could reasonably be expected to know, is relevant to the Insurer’s decision whether to accept the risk of insurance and, if so on what terms. You and the Trustee have the same duty to disclose those matters to the Insurer before you or the Trustee renew, extend, vary or reinstate a contract of insurance. This duty, however, does not require disclosure of a matter that: • • • • diminishes the risk to be undertaken by the Insurer, is of common knowledge, the Insurer knows, or in the ordinary course of business, ought to know, or as to which compliance with the duty of disclosure is waived by the Insurer. Non-disclosure If you or the Trustee do not dislcose to the Insurer every matter that you or the Trustee know or could reasonably be expected to know, that would be relevant to the Insurer’s decision whether to accept the risk of the insurance and if so, on what terms, the Insurer may avoid the contract, or avoid cover in respect of an individual insured member within three years of entering into it, provided that we would not have entered into that contract or accepted cover for the insured member had full disclosure been made. If your non-disclosure is fraudulent the Insurer can avoid the contract, or the cover, at any time. Where the Insurer is entitled to avoid a contract of insurance, or your cover, the Insurer may elect not to avoid it but apply either of the following options: • • reduce the sum that you or an insured member would have been insured for in accordance with formula that takes into account the premium that would have been payable if you or the Trustee had disclosed all relevant matters to the Insurer; or vary the contract in such a way as to place the Insurer in a positon that the Insurer would have been in had you or the Trustee disclosed all relevant matters or not made a misrepresentation. Where the Trustee’s contract or your conver is in respect of death cover, the Insurer may only apply the first of the two options and we must do so within three years of you entering into the contract or us providing cover to the insured member. As a conditon of your membership to the Fund, the Trustee requires you to comply with this Duty of Disclosure and to disclose every matter that you know will be releveant to the Insurer’s decision to accept the risk of insurance, and if so, on what terms. P PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E [email protected] | W www.emplus.com.au Emplus ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 3 of 3
© Copyright 2024