Asgard Personal Protection Package

Transcription

1 Asgard Personal Protection Package Insurance Account Amendment Super & Stand-Alone Use this form if you are a member of Asgard Personal Protection Package and you wish to change your contact details or name, transfer your policy ownership outside of superannuation, reduce or cancel your insurance cover, or change your payment details or adviser details. To avoid any delay in processing your amendment, please ensure you do the following. Complete all the relevant sections, sign and date this form. Attach any required documentation as outlined in the relevant section. Send it to us by either: > > mail: Asgard, PO Box 7490, Cloisters Square WA 6850 > > fax: (08) * > > applicationinsurance@asgard.com.au* * Please do not fax or this form if you are requesting for a change of name (section 3). Note: Do not send us the original copy as well if you are sending this form by fax or . Questions? Call Customer Relations on or asgard.investor.services@asgard.com.au ithis symbol indicates you need to give us more information. 1. Account details Account number Life Insured name Cover Owner name(s) if different from the Life Insured (insurance outside super only) 2. Change of contact details insurance outside super only Please indicate whose details are to be changed by ticking ( ) the appropriate box and completing the new contact details below. Life Insured Cover Owner Change my/our contact details to: Residential address State 111 Postcode 1111 Postal address (if different from residential address) State 111 Postcode Phone (home) Phone (mobile) of 6 Insurance Account Amendment Form

2 3. Change of name Please indicate whose name is to be changed by ticking ( ) the appropriate box and completing the new details below. i Please post with this form a certified copy of your change of name evidence (eg Marriage Certificate, Deed Poll, Change to Company Details form lodged with ASIC, etc). inote: Faxed or ed copy will not be accepted. Life Insured Cover Owner Change my name to: Title Surname Given name(s) Certification of personal documents All copied pages of ORIGINAL documents (including any linking documents) need to be certified as true copies. This certification can be made by any person authorised to take statutory declarations in the State in which the documents are certified. This person must sight the original and the copy, make sure both documents are identical and make sure all pages have been certified as true copies by writing or stamping certified true copy followed by their signature, printed name, qualification (eg Justice of Peace, solicitor, pharmacist, police officer, etc) and date. 4. Transfer of Cover Ownership insurance outside super only Please indicate the new Cover Owner(s) by ticking ( ) the appropriate box and providing the following details for the new Cover Owner(s). Please also complete section 7. If you are transferring to more than one Cover Owner, provide these details for each additional new Cover Owner on a separate signed sheet of paper. The Cover Owner(s) listed in section 1 hereby transfers all of their right, title and interest in the cover to the person(s) listed below. Individual(s) or Individual Trustee(s) Title Surname Given name(s) Residential address State 111 Postcode 1111 Postal address (if different from residential address) State 111 Postcode Phone (Home) Phone (Business) Phone (Mobile) Facsimile of birth Gender 11 / 11 / 1111 Male Female 2 of 6 Insurance Account Amendment Form

3 4. Transfer of Cover Ownership insurance outside super only (continued) OR Company/Corporate Trustee ABN/ACN Contact (Nominated contact person) Postal address State 111Postcode Phone (Home) Phone (Business) Phone (Mobile) Facsimile Reduction of insurance cover amount(s) Please enter the amount of cover you wish to reduce to. Insurance cover type New amount of cover Life Protection $ 1,111,111 (Minimum $50,000) Total & Permanent Disablement Protection 1 $ 1,111,111 (Minimum $50,000) Salary Continuance/ Income Protection $ 11,111 (Minimum $1,000 per month) Reduce Benefit Period to: 2 years Increase Waiting Period to: 60 days 90 days Trauma Protection $ 1,111,111 Critical Trauma Protection $ 1,111,111 Business Expenses Protection $ 11,111 1 If the Total & Permanent Disablement (TPD) cover is held in combination with Life Protection (Life & TPD Protection), TPD cover amount cannot exceed the Life Protection cover amount. ito increase your insurance cover amount(s), please complete the application available from your financial adviser or by calling Customer Relations on Cancellation of insurance Please indicate the insurance cover you wish to cancel by ticking ( ) the appropriate box below. Life Protection TPD Only Life & TPD Protection Salary Continuance Income Protection Business Expenses Protection Trauma Protection Critical Trauma Protection 3 of 6 Insurance Account Amendment Form

4 7. Change of payment details insurance outside super only^ Please indicate below the payment method and frequency you wish to apply for your insurance cover premiums and charges payment. Asgard Investment Account Account number Monthly Quarterly Half-yearly Yearly i For ecash or CASH Connect Account, please also complete and enclose the Direct Debit Request form with this form. Direct debit # i Please complete and enclose the Direct Debit Request form with this form. Cheque # i Please enclose a cheque made payable to Asgard Capital Management Ltd with this form. ^ If your insurance cover is held through an Asgard Super Account, your premiums are automatically deducted monthly from your Asgard Super Account. i To change your bank account details, please complete a Direct Debit Request form. 8. Change of adviser details I authorise Asgard to change the financial adviser on my insurance cover to my new financial adviser whose details are listed below. This authorisation revokes my previous financial adviser s right to information relating to my account and now authorises Asgard to provide information relating to my account. If you have a stand alone policy you authorise Asgard to pay adviser remuneration to your new financial adviser. Dealer name 1 Adviser s name 1 Adviser s phone (business) Adviser s Phone (mobile) Declaration and signature Privacy Statement Why we collect your personal information We collect personal information (including sensitive information e.g. health information) from you to process your amendments. We may also use your information to comply with legislative or regulatory requirements in any jurisdiction, prevent fraud, crime or other activity that may cause harm in relation to our products or services, and help us run our business. If you do not provide all the information we request, we may not be able to process your amendments. Disclosing your personal information We may disclose your personal information to the Insurer, other members of the Westpac Group, anyone we engage to do something on our behalf such as a service provider, and other organisations that assist us with our business. We may disclose your personal information to an entity which is located outside Australia. Details of the countries where the overseas recipients are likely to be located are in the Asgard Privacy Policy. As a provider of financial services, we have obligations to disclose some personal information to government agencies and regulators in Australia, and in some cases offshore. We are not able to ensure that foreign government agencies or regulators will comply with Australian privacy laws, although they may have their own privacy laws. By using our products or services, you consent to these disclosures. 4 of 6 Insurance Account Amendment Form

5 9. Declaration and signature (continued) Other important information We are required or authorised to collect personal information from you by certain laws. Details of these laws are in the Asgard Privacy Policy. The Asgard Privacy Policy is available at asgard.com.au or by calling The Insurer's privacy policy is available at bt.com.au. The privacy policies cover: > > how you can access the personal information we hold about you and ask for it to be corrected; > > how you may make a complaint about a breach of the Australian Privacy Principles, or a registered privacy code, and how we will deal with your complaint; and > > how we collect, hold, use and disclose your personal information in more detail. The Asgard Privacy Policy will be updated from time to time. Where you have provided information about another individual, you must make them aware of that fact and the contents of this privacy statement. Important note The Life Insured only needs to sign this form if there is a change of contact details or change of name for the Life Insured specified in section 2 or 3. The Cover Owner(s) listed in section 1 always needs to sign this form. If ownership of the cover is being transferred, the new Cover Owner(s) also needs to sign below where indicated to accept the transfer of cover ownership and confirm the payment details specified in section 7. Execution by Life Insured Signature of Life Insured Name of Life Insured Execution by Cover Owner(s) listed in section 1 (if different from the Life Insured) Individual(s) or Individual Trustee(s) Cover Owner Signature of Cover Owner Name of Cover Owner OR Company or Corporate Trustee Cover Owner Signature of Director/Secretary/Business Partner 1 Name of Director/Secretary/Business Partner 1 5 of 6 Insurance Account Amendment Form

6 9. Declaration and signature (continued) Signature of Director/Secretary/Business Partner 2 Name of Director/Secretary/Business Partner 2 Execution by new Cover Owner(s) listed in section 4 (if applicable) Individual(s) or Individual Trustee(s) Cover Owner Signature of Cover Owner Name of Cover Owner OR Company or Corporate Trustee Cover Owner Signature of Director/Secretary/Business Partner 1 Name of Director/Secretary/Business Partner 1 Signature of Director/Secretary/Business Partner 2 Name of Director/Secretary/Business Partner 2 Customer Relations: Trustee: BT Funds Management Limited ABN Administrator: Asgard Capital Management Limited ABN Correspondence to: Asgard, PO Box 7490 Cloisters Square WA 6850 Insurer: Westpac Life Insurance Services Limited ABN AS vx 6 of 6 Insurance Account Amendment Form