*SA GH1* Application for insurance cover form and personal health statement

Transcription

1 Application for insurance cover form and personal health statement Please complete this form in BLACK PEN and CAPITAL LETTERS. ABOUT THIS FORM Complete this form if you wish to apply: > > for Death cover only, Death and Total and Permanent Disablement (TPD) cover and/or Income Protection cover above the default level > > for Income Protection cover to age 65 > > for additional units of TPD > > to change or nominate a waiting period > > to remove the New Events Cover condition Do not use this form if you wish to: > > apply for the default level of cover > > reinstate default cover after you previously elected to cancel it Your Member No. In both these cases, please complete the Application for default insurance cover form and statement of good health available at mediasuper.com.au/forms ANY QUESTIONS? For assistance call our Super Helpline on COMPLETED FORM Please complete all sections of this form as applicable, sign at Steps 7 8, and return the completed form to:. The fully completed and signed form must be received by Media Super within 31 days of it being signed and dated. If you fail to sign the form, we will be unable to assess and process your application. NOTICES FROM OUR INSURER (HANNOVER) DUTY OF DISCLOSURE Before you enter into a life insurance contract with us, whether on your own behalf or on behalf of another person, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure and the terms of that insurance. This duty of disclosure continues after you have completed this statement until the cover has been issued by us. The same duty applies before you extend, vary or reinstate the contract. You do not need to tell us anything that: > > reduces the risk we insure you for; or > > is common knowledge; or > > we know or should know as an insurer; or > > we waive your duty to tell us about. If the insurance is for the life of another person and that person does not tell us everything he or she should have, this may be treated as a failure by you to disclose. If you or the person who becomes the life insured under the policy do not tell us something In exercising the following rights, we must consider whether different types of cover can constitute separate contracts of life insurance. If they do, we may apply the following rights separately to each type of cover. If you or the life insured do not tell us something that you or they are required to tell us, and we would not have insured on the same terms if we had been told, we may avoid the cover within 3 years of issuing it. If we choose not to avoid the cover, we may, at any time, reduce the amount for which you or the life insured have been insured. This would be worked out using a formula that takes into account the premium that would have been payable if you and the life insured had told us everything you should have. However, for death cover, we may only exercise this right within 3 years of issuing the cover. If we choose not to avoid the cover or reduce the amount for which you or the life insured have been insured, we may, at any time vary the cover in a way that places us in the same position we would have been in if we had been told everything we should have been told. However, this right does not apply to death cover. If the failure to tell us is fraudulent, we may refuse to pay a claim and treat the cover as if it never existed. PRIVACY COLLECTION NOTICE The Privacy Act 1988 sets out a number of principles that we must comply with in the collection, security, storage, use and disclosure of personal information. These principles are known as the Australian Privacy Principles. Collection and use: Your personal information is being collected by Hannover Life Re of Australasia Ltd. We collect personal information so that we can assess and process your application for insurance, and assess any claims made by you or on your behalf. If you fail to provide us with all or part of the personal information we require, we may be unable to assess and process your application for insurance or assess and pay any claim. We may also use information for regulatory and compliance purposes. This may include conducting sanctions screening of policy holders. Disclosure: We may disclose your personal information to other organisations for the same purposes as we collected it. We may disclose your personal information to medical practitioners, health service providers, legal and any other professional advisers, agents or consultants including accountants, third parties authorised by you, other insurers and reinsurers, our parent company, investigators and loss assessors, external dispute resolution bodies, legal tribunals and courts, the trustee and the administrator of superannuation funds, interpreters, and regulatory bodies, government agencies, law enforcement agencies or, as required, other persons authorised or permitted by law. Overseas disclosure: We may disclose your personal information to our parent company in Germany for the same purposes as we collected it (see Collection and Use above). We may also disclose your personal information to other overseas recipients (including, for example, our reinsurers who are located overseas) for the same purposes as we collected it. For further information on the locations where your personal information may be disclosed, please refer to our privacy policy, which is available at Access: You may request access to the personal information we hold about you. We may be entitled to deny your request for access in some circumstances. If we deny your request, we will tell you why. Your right to access your personal information is set out in our Privacy Policy. Contact: For more information about our privacy practices, please refer to our Privacy Policy or contact us as follows: The Privacy Officer. Hannover Life Re of Australasia Ltd. Level 7, 70 Phillip Street, Sydney NSW Telephone: (02) Facsimile: (02) privacyofficer@hlra.com.au Issued November 2017 by Media Super Limited ABN AFSL as Trustee for Media Super ABN USI MSUP 52901

2 STEP 1 - Your personal details Mr/Mrs/Ms/Miss/Dr Gender Date of birth Surname Male Female Given names Residential address (must be provided) State Postcode Postal address (if different to above) State Postcode Daytime telephone ( ) address Mobile number Continue to Step 2. STEP 2 Additional personal details The information requested in this section is required by the Insurer of Media Super. It is used for the purpose of determining the level of risk and therefore the level of insurance cover allowable to each individual. Are you applying for: Cover as an Employer-sponsored member Cover as a Personal account member Note: If you are not sure which type of member you are please call our Super Helpline on Your employer s name Date commenced with employer I authorise an underwriting service representative to contact me if further information is required. I can be contacted at the following times: Monday Tuesday Wednesday Thursday Friday Any business day Between and Please tick your preferred contact method: Home phone Work phone Mobile Continue to Step 3.

3 STEP 3 Occupation/Duties Occupation Mode of employment Full-time Part-time Casual/Contract Other Describe all present duties in the table below (please complete both percentage of time and specific duties in all cases) Please describe your specific duties and where they are performed. Type of work % of time Please note that the examples below are a guide only. Sedentary/administration (e.g. filing, computer work, answering telephone, reception duties, etc.) Manual work light (e.g. driving, warehousing, surveying, lifting under 10kg, etc.) Manual work heavy (e.g. bricklaying, lifting over 10kg, painting, carpentry, mechanic, etc.) How many hours do you work per week? Annual salary (before tax) $,. Continue to Step 4 if you wish to apply for Death and TPD cover. Continue to Step 5 if you are only applying for Income Protection cover. STEP 4 Your insurance: Death only or Death and TPD Please select one option below: 1. Death cover only Nominate the total number of units that you require ($0.29 per week each) OR Nominate a Fixed-dollar cover amount $,. 2. Death and TPD cover Nominate the total number of units that you require ($0.44 per week each) OR Nominate a Fixed-dollar cover amount $,. Note: any existing Unit-based cover will be converted to Fixed-dollar if Fixed-dollar cover is approved. 3. Additional units of TPD cover Nominate the total number of additional TPD units you require ($0.15 per week each) 4. New Events Cover condition I wish to apply to remove the New Events Cover condition. Note: Any approved cover will replace any existing cover. Where you have Death and TPD cover, your Death cover must be equal or higher than your TPD cover. Continue to Step 5 if you wish to apply for Income Protection cover. Continue to Step 6 if you are only applying for Death cover only or Death and TPD cover.

4 STEP 5 Your insurance: Income Protection Members can apply for additional units in excess of the Standard Default Cover and up to $12,000 per month (subject to a New Events Cover condition). Any applications for cover above $12,000 per month, but up to the maximum benefit limit of $30,000 is subject to underwriting. Please select the below option(s) applicable to you: 1. I wish to apply for Income Protection cover with a 5 year benefit period. (Each unit of cover represents $500 of cover per month) Number of units to a value of: $,. per month Please select your waiting period. I wish to elect the following waiting period: 30 days 60 days 90 days If your value of cover is greater than $12,000 per month, you are required to complete the Personal Health Statement in Step 6. Otherwise continue to Step I wish to apply for Income Protection cover with a benefit period to age 65. (Each unit of cover represents $100 of cover per month) Number of units to a value of: $,. per month Please select your waiting period. I wish to elect the following waiting period: 30 days 60 days 90 days You are required to complete the Personal Health Statement. Please continue to Step I wish to change my waiting period. (refer to your welcome letter) I wish to elect the following waiting period: 30 days 60 days 90 days If you are decreasing your waiting period, you are required to complete the Personal Health Statement in Step 6. Otherwise continue to Step I wish to apply to remove the New Events Cover condition. You are required to complete the Personal Health Statement. Please continue to Step 6. STEP 6 Personal Health Statement PART A The Insurer will process most applications using the information in Step 6. In some cases the Insurer may require additional details, such as financial information, medical reports, blood test results, or may require you to complete a medical examination. Your cover will commence when your application is approved by the Insurer. PLEASE COMPLETE ALL QUESTIONS IN PART A. 1. What is your height? cm or feet and inches 2. What is your weight? If you answered Yes to this question, please advise the relationship, condition and age of the diagnosed: 4. Do you engage in, or intend to engage in (other than as a fare-paying passenger) any hazardous activities such as flying, motor racing, parachuting, hang gliding or diving? If Yes, please provide details of the activity and the frequency with which you participate in this activity, including maximum speed/ height/depth: kg or stone and pounds Has your weight varied by more than 10kg (22 pounds) during the past 12 months? Yes No If Yes, please provide details below: Please tick YES or NO boxes for each of the following questions: At any time in your life have you ever suffered from, experienced symptoms, or been diagnosed with any of the following? 3. Have any of your near relatives (i.e. your father, mother, brothers or sisters) been diagnosed prior to age 60 with hereditary disorders such as diabetes, cancer, heart disease, mental disorder, haemophilia or Huntington s chorea? I participate in this activity times per year. 5. Heart trouble, heart murmur, high blood pressure, high cholesterol, chest pain, rheumatic fever, palpitations, stroke or vascular disorder? 6. Have you EVER been infected with, or have you ever tested positive for AIDS (Acquired Immune Deficiency Syndrome), HIV (Human Immunodeficiency Virus) or Hepatitis B or C, or are you awaiting the results of such a test? OR Have you EVER injected yourself or been injected with any drug not prescribed by a medical practitioner? OR Have you EVER worked as or engaged in sexual intercourse with a prostitute? OR

5 STEP 6 Personal Health Statement (continued) YES Have you EVER engaged in sexual intercourse with a person who you know or suspect to be HIV positive and/or know or suspect to have injected non-prescribed drugs? OR To the best of your knowledge are you in a highrisk category for contracting, the HIV virus (Human Immunodeficiency Virus) that causes AIDS (Acquired Immune Deficiency Syndrome)? 7. Disease related to kidney, bladder, prostate, bowel, stomach or liver (including Hepatitis B and C)? 8. Mental illness, depression, anxiety, chronic fatigue, nervous condition, stress or post traumatic stress disorder? 9. Diabetes, thyroid or glandular trouble? 10. Asthma, lung conditions and breathing disorder? 11. Back, neck, shoulder, or knee pain; strain, sciatica, whiplash, or any disorder of the spine or neck, or any disorder of the joints, muscles, ligaments, cartilage or limbs (including broken bones)? 12. Disorder of the eyes, ears or skin (excluding prescriptions for glasses or contact lenses)? 13. Disease of the brain, fits or dizziness of any kind, or persistent headaches, nervous system or epilepsy? 14. Cancer, leukaemia, tumour of any kind or blood disorder? 15. Are you currently off work, or unable to perform all your usual duties on a permanent full-time basis, or are you receiving any form of medical treatment? 16. To the best of your knowledge, have you taken more than a total of seven days off your work over the past 12 months due to illness or injury (other than cold or flu)? 17. (a) During the last twelve months have you smoked tobacco or any other substance? If Yes, please state the type and quantity per day: NO If you answered YES to ANY of the previous questions where there was no room to provide further detail, please provide it here. If further space is required, please attach a separate signed and dated sheet and identify the question number concerned. PART B Please complete all questions in this section, Part B, if you answered YES to ANY questions in Part A and/or you are applying for more than $500,000 of Death cover or Death and TPD cover or if you wish to apply for more than 24 units ($12,000 per month) of Income Protection cover. If you DIDN T answer YES to ANY questions in Part A continue to Step 7. If further space is required, please attach a separate signed and dated sheet and identify the question number concerned. 1. Have you ever had an application for life, disability, accident or sickness insurance declined, postponed, modified or accepted on special terms (eg. exclusions or loadings)? If Yes, please provide details below: 2. Have you ever made a claim, or are any claims pending or intended for any type of accident or sickness, lump-sum total and permanent disablement, workers compensation or personal injury insurance? If Yes, please provide details: (b) Have you ever been advised by a medical practitioner to give up or reduce the amount of smoking on specific medical grounds, or have you been informed that you have a medical condition as a result of your smoking? 18. (a) Do you consume alcohol? If Yes, do you consume 3 or more drinks in any one day, or more than 5 drinks in any one sitting? If Yes, please state the type and number of standard drinks per week? Beer Qty per week Wine Qty per week Spirits Qty per week Other Qty per week (b) Have you ever been advised by a medical practitioner to give up or reduce the amount of alcohol consumed on specific medical grounds, or have you been informed that you have a medical condition as a result of your alcohol consumption? 3. Do you currently have or are you currently applying for Death cover only, TPD, or Income Protection Insurance with any other superannuation fund or insurer? If Yes, please provide details below: Company name: Type of cover: Amount insured: Will this policy be discontinued/replaced 4. Have you ever had any of the following or, to the best of your knowledge, do you currently have any of the following: (a) Ill health or disability? (b) Asthma, sleep apnoea, bronchitis, persistent cough or any other chest or lung troubles or allergy?

6 STEP 6 Personal Health Statement (continued) (c) Ulcers, bowel trouble or recurring indigestion? (d) Stress, anxiety, depression, mental or nervous disorders, alzheimers disease or dementia? (e) Kidney or bladder problems, renal colic or stones, nephritis, pyelitis or cystitis? (f) Arthritis, gout, fibromyalgia, tendonitis, tenosynovitis, RSI, or any regional pain syndrome, Chronic Fatigue Syndrome (Myalgic Encephalomyelitis)? (g) Cancer, tumour, cyst, growths of any kind, or breast lumps (even if you have not seen a doctor)? (h) Varicose veins, hernia or skin trouble? (i) Any abnormality affecting eyesight, hearing, speech or physical mobility? (j) Anaemia, haemophilia or any other disease of the blood? (k) Bowel, liver, or gall bladder disease or hepatitis? (l) Any other disease or condition or relevant symptoms lasting more than four weeks or of an ongoing nature? (m) Coughing of blood or passing of blood from the bowel or in the urine? (n) Are you currently receiving or considering receiving medical attention, or taking prescribed drugs (other than for contraceptive purposes?) 5. Question 5 is for females only (a) Are you currently pregnant? If Yes, please provide due date: (b) Have you had any complications with pregnancy or childbirth? If Yes, please provide details: (c) Have you ever had an abnormal pap smear, breast ultrasound or mammogram? If Yes, please provide details: Date of your last consultation Outcome: (b) If you have been attending your usual doctor for less than 12 months, please advise name, number and address of the doctor who has details of your medical history: Full name of usual doctor/medical centre Telephone number ( ) Address of doctor Reasons for last consultation: Date of your last consultation Outcome: (c) If you have more than one usual doctor, please provide details of additional doctors below: Full name of usual doctor/medical centre Telephone number ( ) Address of doctor 6. (a) Usual doctor or medical centre details: Full name of usual doctor/medical centre Telephone number ( ) Address of doctor Reasons for last consultation: Date of your last consultation Outcome: Reasons for last consultation:

7 STEP 6 Personal Health Statement (continued) DETAILS OF PERSONAL HEALTH QUESTIONS Please complete this section if you answered YES to ANY questions at Question 4 in Part B. If you DIDN T answer YES to ANY questions at Question 4 in Part B continue to Step 7. Note: If you answered Yes to more than two questions, please photocopy this page, complete this section, and attach the pages to this application. 2. Did you answer Yes to any other questions in PART B? If so, please write down the next question number that you answered. Please advise if illness, injury or test: Main symptoms/causes: 1. Did you answer Yes to any questions in PART B? If so, please write down the first question number that you answered. Please advise if illness, injury or test: Date commenced: Time off work: Main symptoms/causes: Please tick YES or NO boxes for each of the following questions: Date commenced: Time off work: Has the condition recurred? If Yes, state date range: From: Please tick YES or NO boxes for each of the following questions: Has the condition recurred? If Yes, state date range: From: To: Have you fully recovered? To: Have you fully recovered? If Yes, give date: If No, please provide degree of recovery % Full details of treatment: If Yes, give date: If No, please provide degree of recovery % Full details of treatment: Date of last symptom: Further treatment recommended? If Yes, please give details: Date of last symptom: Further treatment recommended? If Yes, please give details: Full name and address of doctor or hospital consulted: Full name and address of doctor or hospital consulted: Does your usual doctor have details of this condition? Other information: Does your usual doctor have details of this condition? Other information: 3. Did you answer Yes to any additional questions in PART B? If so, please photocopy this page, and fill in the details for these additional questions and attach the pages to this application. Continue to Step 7.

8 STEP 7 Hannover Life Re Consent, Declaration & Authority Please read the Consent, Declaration & Authority information below and sign and date to acknowledge you have read and understood it. Authority to provide information I understand that in order to assess and process my application, Hannover Life Re of Australasia Ltd. ( HLRA ) may need health and employment information about me and I consent to HLRA obtaining information about me from any of the parties listed below. I also understand that if I apply for increased or different insurance cover, HLRA may require further information about me and consent to HLRA obtaining such further information as and when required, from any of the parties listed below. I understand that if I or anyone else on my behalf, makes a claim for a benefit, HLRA will need information about me in order to assess and process the claim, and I also consent to HLRA obtaining information about me in relation to any claim I make from any of the following parties listed below: Parties to whom this consent is directed*: > > any hospitals or medical practitioners that have examined me or reviewed any diagnostic medical test in relation to me; > > any current or former employer; > > any professional adviser, such as your accountant or lawyer; > > any insurance company (including HLRA s parent company or reinsurance company) that may have relevant information about me; > > the trustees of my superannuation fund, or any organisation appointed by the trustees of my superannuation fund to receive or give information. For the purpose of this application and any future application and any claim for a benefit, I also consent to HLRA disclosing information about me to any of the parties mentioned above, insofar as such disclosures are necessary for HLRA to perform its functions. Declaration I have read and carefully considered the questions on this Form. I have also read the Duty of Disclosure and all my answers on this Form are true and correct and I understand that my duty to disclose continues after I have completed this application until Hannover Life Re of Australasia Ltd. has accepted the application. I acknowledge: a) this Declaration is part of an application for Life, TPD, GIP and Trauma insurances (where this benefit applies), and the making of a false statement or b) that, if I fail to provide all or part of the information required, or consent to HLRA obtaining such information, as it requires, this application will not be assessed and processed. c) that at the date of this application I am not absent from work for reasons of illness or injury and I am performing all of the duties of my usual occupation. * Under the Insurer s industry Code of Practice if HLRA require information from other people, such as the parties that are listed in this authority, the Insurer may ask you for a general authority to obtain information about you from them such as this. If you agree to give HLRA this general authority they will use it to obtain information that they reasonably believe is relevant to your application for insurance cover or to a claim. If you make a claim you can cancel this authority by notifying HLRA, and instead authorise HLRA to request particular information from particular sources. However, you should be aware that this could cause delays in the assessment of your claim or mean that HLRA are unable to assess your claim, and HLRA may require further authorities before they can progress to the assessment of your claim. To acknowledge that you accept the information above, please provide your details in the boxes below. Member details Given names Surname Date of birth Member signature Date signed x Continue to Step 8.

9 STEP 8 Sign the form By signing this form I acknowledge that I: > > have read and carefully considered the questions in the Personal health statement above, and all answers provided are true and correct; > > have read the conditions and directions for completion attached to this form, and agree to be bound by them; > > have read and understand the Duty of Disclosure and Non-Disclosure sections below, and I have not withheld any information that may affect the Insurer s decision as to whether to accept my Application for insurance cover form. I understand that the Duty of Disclosure continues after I have completed this statement until my application has been accepted by the Insurer in writing; > > am currently gainfully employed and able to attend work and perform my normal duties, without restriction due to injury or illness; > > have read the Member Guide PDS and associated reference materials. 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 non-sensitive 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 signed x The fully completed and signed form must be received by Media Super within 31 days of it being signed and dated. IMPORTANT NOTICE Commencing cover Your insurance cover or increase in cover will commence when (and if) the Insurer accepts your application. You will be notified in writing. Interim accident cover applies during the processing period under the conditions set in the Member Guide Product Disclosure Statement (PDS) and associated reference materials. Cooling-off Period Members will have 28 days (known as the cooling-off period) from the date of their welcome letter to cancel their insurance and have their premiums refunded. This cooling-off period will not apply if there has been any claim or potential insurance claim made. Further, no benefit will be payable to a member who has cancelled their cover during the cooling-off period.