BOCSUPER. 1. Personal details. Important notice. Your duty of disclosure. Title. Surname. Given names. Date of birth. Home address.

Transcription

1 BOCSUPER 1. Personal details Title Surname Given names Date of birth Home address Work phone number Home phone number Mobile phone number BOC Super member number See how BOC Super protects your personal information on page 6. zz If you are a permanent BOC employee and a member of BOC Super, you can apply for additional voluntary death insurance cover. zz If you apply within 90 days of commencing employment with BOC and join the Fund when first eligible you can have $200,000 of additional voluntary death insurance without completing the health questionnaire. zz The cost of insurance is deducted from your account. The cost depends on your age and your occupational status. See the PDS for details. If there is not enough in your account to cover the fee, your additional voluntary death insurance will stop. Important notice BOC Superannuation Pty Limited, as Trustee of the BOC Gases Superannuation Fund (BOC Super), has taken out a contract of insurance with OnePath Life Limited ABN , AFSL ( OnePath Life ) to provide the insurance benefits in the Fund. On becoming a member, your insured benefits and insurance coverage are subject to the terms and conditions of this contract of insurance. Your duty of disclosure Before completing this form, please see the duty of disclosure on page 5. Page 1 of 6 1

2 2. How do you qualify to apply? Which of the following requirements do you satisfy? OR I am an Australian citizen, permanent resident of Australia or a New Zealand citizen permanently residing in Australia I hold a visa. Please provide details of the visa 3. How much insurance do you want? Please specify $ of insurance cover To apply for voluntary insurance cover, you must be aged under 69 when you apply, and either: z An Australian or New Zealand citizen, z A permanent Australian resident, or z A holder of a valid visa permitting residency and employment in Australia. You must apply for insurance in multiples of $1, Occupation Please tick YES or NO to each of the following questions. YES NO Do you work in an office or similar environment? Do you spend at least 80% of your working time in an office? Please tick if you work in any of the following occupations: management clerical marketing administration accounting other sedentary duties please specify below no, none of the above If you don t fit the definition of white collar your occupation will be classified as blue collar. My occupation at BOC Limited is: Page 2 of 6 2

3 You do not need to complete this section if you are applying for up to $200,000 of additional voluntary death insurance cover within 90 days of commencing employment with BOC and joining the Fund when first eligible. 5. Insurer s short health questionnaire What is your current height? What is your current weight? cm kg Please tick YES or NO to each of the following questions. 1. Are you at the date of this application off work due to injury or illness or restricted from performing all the usual duties of your occupation due to injury or illness? 2. Are you currently receiving any form of medical treatment (other than for cold and flu)? 3. To the best of your knowledge have you taken more than a total of seven days off work over the past 12 months due to illness or injury (other than colds or flu)? YES NO If you answer yes to any of these questions, or are applying for more than $750,000 of insurance, you will need to complete a full health questionnaire using the insurer s Personal Statement. This is available at or from the BOC Super Helpline on Have you ever received a Total and Permanent Disability (TPD) benefit or are you eligible to claim a TPD benefit either from this Fund or any other source? 5. To the best of your knowledge are you suffering from Acquired Immune Deficiency Syndrome (AIDS), infected with HIV or carrying antibodies to HIV? At any time in your life have you ever suffered from, experienced symptoms, or been diagnosed with any of the following: 6. High blood pressure, high cholesterol, heart complaint, murmur, palpitations or chest pain, stroke, diabetes, thyroid or glandular disorder, cancer, tumour or growth including breast lumps or skin lesions/moles (even if you have not seen a doctor)? 7. Back or neck pain/disorder, musculo-skeletal symptoms or any joint disorder, gout, arthritis, repetitive strain injury, paralysis of any kind or chronic fatigue syndrome, epilepsy or neurological disorder, mental/nervous disorder including stress, anxiety or depression? 8. Kidney, bowel, bladder, gall bladder, liver disease or disorder, hepatitis, hernia, blood disorder, sleep apnoea, asthma, persistent cough or any lung complaint, any abnormality of hearing, speech or eyesight (excluding glasses or contact lenses)? Page 3 of 6 3

4 6. Declaration Please note, your signature below indicates you have read, understood, and agree with the following statements. By signing this form, I declare that: z I am applying for additional voluntary death insurance cover in BOC Super and understand that this will be applied in addition to any existing insurance I may have in the Fund. z I understand that additional voluntary death insurance cover will only commence after my application has been accepted by the insurer. While my application is being considered, I am eligible for accidental death cover for up to 90 days (refer to the Product Disclosure Statement for details). z I acknowledge that to take advantage of the introductory offer of $200,000 of additional voluntary death insurance, my properly completed application must be received by the Fund s administrator within 90 days of commencing employment with BOC and joining the Fund when first eligible. z I acknowledge that if I do not complete this form correctly or I do not sign and date this form, my application will not be considered by the insurer. z I have read and understood the Your duty of disclosure section of this application. I have not withheld any information that may affect the BOC Super s insurer s decision as to whether to accept this application. I understand that the duty of disclosure continues after I have completed this application until I am notified of acceptance in writing by the Trustee. z In accordance with BOC Super s Privacy Policies, I consent to the Trustee providing BOC Super s insurer with my personal information (including health information) necessary for the administration of the insurance policy or the processing of any claim. z I understand and consent to my information being collected, disclosed and used in the manner set out in this form. z I consent to BOC Super s Insurer (OnePath Life) collecting, using, storing and disclosing my personal information (including health information) to assess and process my application, as well as to manage and administer my insurance in accordance with the ANZ Privacy Policy (It may be downloaded from onepath.com.au/privacy-policy or contact the Fund for a copy). The parties to whom OnePath Life may routinely disclose the information include: the policy owner and the policy owner s administration services provider; other ANZ group companies; any agent, contractor or service provider that helps OnePath Life/ANZ carry out its activities; and organisations that assist OnePath Life/ANZ to prevent unlawful activity. I understand that some of the recipients of this information may be located outside of Australia and may not be established in or do not carry on business in Australia. ANZ s Privacy Policy contains information about where these overseas recipients are located and also details: how I can access and correct my information; how I can raise concerns about privacy breaches; and how ANZ will deal with these matters. z I have read the Fund s Product Disclosure Statement, and acknowledge that I have received all the information I require in order to exercise the choices I have made. z I understand that the fee for the additional voluntary death insurance cover will be deducted each month from my account in BOC Super and that insurance will stop if there is not enough in my BOC Super account to pay the fee. z I have read and carefully considered the questions in this application, and the above statements and information are correct and true. I acknowledge responsibility for their completeness and accuracy whether this form has been completed by me or by another person on my behalf. Signature Date / / Page 4 of 6 Please return your completed form and any other required documentation to: The Fund Administrator, BOC Gases Superannuation Fund, GPO Box 4303, Melbourne VIC 3001 Issued by BOC Superannuation Pty Ltd, ABN , AFS Licence No , as Trustee of the BOC Gases Superannuation Fund, ABN MySuper Authorisation number Form issued May 2016.

5 BOCSUPER The Trustee who enters into a life insurance contract in respect of your life has a duty, before entering into the contract, to tell OnePath Life Limited (the Insurer) anything that they know, or could reasonably be expected to know, may affect the Insurer s decision to provide the insurance and on what terms. The Trustee has this duty until the Insurer agrees to provide the insurance. The Trustee has the same duty before it extends, varies or reinstates the contract. The Trustee does not need to tell the Insurer anything that: reduces the risk the Insurer insures you for; or z is of common knowledge; or z the Insurer knows or should know as an insurer; or z the Insurer waives your duty to tell the Insurer about. In order for the Trustee to comply with the duty of disclosure, we require you to tell us (the Trustee and the Insurer), anything you know, or could reasonably be expected to know, that may affect the Insurer s decision to insure you and on what terms. If you do not tell the Trustee and Insurer something that you know, or could reasonably be expected to know, may affect the Insurer s decision to provide the insurance and on what terms, this may be treated as a failure by the Trustee entering into the contract to tell the Insurer something that we must tell the Insurer. If you do not tell the Insurer something In exercising the following rights, the Insurer may consider whether different types of cover can constitute separate contracts of life insurance. If they do, the Insurer may apply the following rights separately to each type of cover. If you do not tell the Insurer and the Trustee anything you are required to, and the Insurer would not have provided the insurance or entered into the same contract with the Trustee if you had told the Insurer and the Trustee, the Insurer may avoid the contract within 3 years of entering into it. If the Insurer chooses not to avoid the contract, the Insurer may, at any time, reduce the amount of insurance provided. This would be worked out using a formula that takes into account the premium that would have been payable if you had told the Insurer and the Trustee everything you should have. However, if the contract provides cover on death, the Insurer may only exercise this right within 3 years of entering into the contract. If the Insurer chooses not to avoid the contract or reduce the amount of insurance provided, the Insurer may, at any time vary the contract in a way that places the Insurer in the same position it would have been in if you had told the Insurer and the Trustee everything you should have. However this right does not apply if the contract provides cover on death. If the failure to tell the Insurer is fraudulent, the Insurer may refuse to pay a claim and treat the contract as if it never existed. Issued by BOC Superannuation Pty Ltd, ABN , AFS Licence No , as Trustee of the BOC Gases Superannuation Fund, ABN MySuper Authorisation number May 2016.

6 BOCSUPER Privacy Collection Statement BOC Super is administered by us along with our service provider, Mercer Outsourcing Australia Pty Ltd (Mercer). We collect, use and disclose personal information about you in order to manage your superannuation benefits and give you information about your super. We may also use it to supply you with information about the other products and services offered by us and our related companies. If you do not wish to receive marketing material, please call the BOC Super Helpline on Our Privacy Policies are available to view at or you can obtain a copy by calling the BOC Super Helpline on If you do not provide the personal information requested, we may not be able to manage your superannuation. We may sometimes collect information about you from third parties such as your employer, a previous super fund, your financial adviser, our related entities and publicly available sources. We may disclose your information to various organisations in order to manage your super, including your employer, our professional advisors, insurers, our related companies which provide services or products relevant to the provision of your super, any relevant government authority that requires your personal information to be disclosed, and our other service providers used to assist with managing your super. In managing your super your personal information will be disclosed to service providers in another country, most likely to Mercer s processing centre in India. Our Privacy Policies list all other relevant offshore locations. Our Privacy Policies set out in more detail how we deal with your personal information and who you can talk to if you wish to access and seek correction of the information we hold about you. They also provide detail about how you may lodge a complaint about the way we have dealt with your information and how that complaint will be handled. If you have any other queries in relation to privacy issues, you may call the BOC Super Helpline on or write to our Privacy Officer, BOC Gases Superannuation Fund, GPO Box 4303, Melbourne VIC View our Privacy Policies at or call the BOC Super Helpline on if you have any questions. Issued by BOC Superannuation Pty Ltd, ABN , AFS Licence No , as Trustee of the BOC Gases Superannuation Fund, ABN MySuper Authorisation number May 2016.