*SA B1* Application for early release of superannuation benefits on grounds of permanent incapacity form ABOUT THIS FORM IF YOU NEED HELP

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1 Application for early release of superannuation benefits on grounds of permanent incapacity form Please complete this form in BLACK PEN and CAPITAL LETTERS. ABOUT THIS FORM > > If you have insurance covering disablement, do not use this form. > > The Trustee reserves the right to request further information including medical reports at the cost of the member. > > Please ensure that every question is answered. Incomplete forms will be returned and will result in a delay in processing your request for an early release of your preserved benefits. > > Your treating medical practitioner and another medical practitioner who is a specialist in their field must complete the relevant Certificate of Medical Attendant forms. Please contact us to obtain copies of the applicable forms. Your Member No. > > Questions are to be answered by you or by a person acting on your behalf only if your treating doctor certifies that you are unable to sign. IF YOU NEED HELP For assistance call our Super Helpline on Please complete all sections of this form as applicable, sign at Step 6, and return the completed form to. STEP 1 - Your personal details Mr/Mrs/Ms/Miss/Dr Gender Date of birth Male Female / / Given names Residential address (must be provided) Postal address (if different to above) address number Name of your employer PROVIDING YOUR ADDRESS Having your address means we can keep you up-to-date with information through our e-newsletter Imprint. Issued August 2015 by Media Super Limited ABN AFSL as Trustee for Media Super ABN USI MSUP 37423

2 STEP 2 Employment history Please state your employer history, beginning with your occupation at the time of your disablement. Please state years of employment beside each occupation. Date last worked? / / STEP 3 Qualifications and training Secondary to what age? TAFE University Have the qualifications been completed? YES NO Other trade / Course qualifications Please list the other training you have undertaken: CONTINUED OVER >

3 STEP 3 Qualifications and training (continued) STEP 4 Reason to cease work Please state the nature of the condition(s) that has caused you to cease work:

4 STEP 5 Details of registered medical practitioners Please list the details of the registered medical practitioners you have consulted regarding this condition(s):

5 STEP 6 Sign the form I, (Please print name) Address Declare that the information given in this form is true and correct in every detail. I authorise any person, hospital, doctor who has been or will be attending me, or any employer to provide Media Super with any information that it may require in the consideration of this claim. And in relation to my privacy I acknowledge that I understand: > > Media Super collects personal information, including sensitive information such as health information, in order to: process applications for, and facilitate the provision of, its superannuation fund products and services; establish and maintain insurance cover; assess and process claims; and to comply with its statutory obligations. Media Super may also collect nonsensitive personal information in order to send information about other products or services which may be of interest to me; > > this information may be disclosed to third parties who assist Media Super in providing its products and services, including the Fund s administrator, Mercer Outsourcing (Australia) Pty Ltd (Mercer), insurers, mail houses, professional advisers, other super funds and financial institutions to which a benefit may be paid. Some of these service providers may be located overseas, in countries including the UK, USA, New Zealand, Bermuda, Singapore or India; > > for further details including how to access or correct my personal information, or how to make a complaint about the way Media Super deals with my information, I can refer to Media Super s Privacy Policy which is available at mediasuper.com.au/privacy-policy or by phoning ; > > and consent to my information being collected, disclosed and used in the manner set out in this form; and > > from time to time, Media Super may send its members communication material about products and services available to Media Super members. I understand that I may opt out from those communications in accordance with the Privacy Policy. Member signature Date x / / Name of witness Witness signature Date x / /