Application for default insurance cover form and statement of good health Please complete this form in BLACK PEN and CAPITAL LETTERS. ABOUT THIS FORM Complete this form if you wish to: > > Apply for or reinstate default Death and Total and Permanent Disablement (TPD) cover and/or Income Protection cover. If you have questions about the form: > > Please call our Super Helpline on 1800 640 886. Your Member No. COMPLETED FORM Please complete all sections of this form as applicable, sign at Steps 5 and 6, 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 www.hannover-re.com/1094181/australia_lh_privacy 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 2000. Telephone: (02) 9251 6911 Facsimile: (02) 9251 6862 Email: privacyofficer@hlra.com.au Issued July 2018 by Media Super Limited ABN 30 059 502 948 AFSL 230254 as Trustee for Media Super ABN 42 574 421 650 USI 42574421650001. MSUP 53568
STEP 1 - Your personal details Mr/Mrs/Ms/Miss/Dr Gender Date of birth Surname Male Female Given names Residential address (must be provided) Postal address (if different to above) Daytime telephone ( ) Email address Mobile number Age Height Weight cm kg What is your present occupation and duties performed? Amount of manual work Hours worked per week % PROVIDING YOUR EMAIL ADDRESS Having your email address means we can keep you up-to-date with information through our e-newsletter. Continue to Step 2 STEP 2 Type of insurance cover Please select the type of cover that you require Death and TPD cover @ $0.44 per unit per week AND/OR Income Protection cover @ $1.33 per unit per week Note: The number of default units that you are entitled to is based on your age next birthday. Please refer to the Member Guide Product Disclosure ment (PDS) and associated reference materials for the default number of units. All cover requested will be subject to acceptance by the Insurer and will commence on the date we advise in writing. Continue to Step 3.
STEP 3 ment of good health Part A Please answer all questions. If you answer YES to any of the questions below, full insurance underwriting will be required. 1. Do you have any injury or illness which restricts you, or is likely to restrict you in the future, from carrying out, on a full-time basis, all the identifiable duties of your current employment? ( Full-time means more than 30 hours a week on an ongoing basis. It is not necessary that you work full-time, but only that you have the physical and mental capacity to do so). YES NO 2. Have you ever submitted a claim for TPD or Terminal Illness or are you eligible for or entitled to a claim from any superannuation fund or any insurance policy? YES NO 3. Do you have, or have you had, any disease, illness or injury, or any other conditions (other than colds, flu or mild asthma) which: (a) has required more than a total of two weeks off work during the past 12 months, YES NO (b) has recurred more than twice in the past two years and/or is currently causing you symptoms or requiring treatment? YES NO Continue to Step 4 if you answered YES to ANY of the above questions. Continue to Step 5 if you answered NO to ALL of the above questions. STEP 4 ment of good health Part B Please provide the following details for each condition/complaint: If more space is required please attach an additional page to your application. Nature of condition/complaint Date commenced Duration of illness or injury Time off work Details of any treatment or operation performed Degree of recovery Name(s) and address(es) of doctor(s) or hospital(s) consulted Name and address of your regular doctor Name Address Date of last visit Reason for visit and result Continue to Step 5
STEP 5 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 6.
STEP 6 Sign the form By signing this form I acknowledge that: > > I have read and carefully considered the questions on this form and all the statements are true and correct in relation to me. > > this Declaration is part of an application for life and disability insurance (where this benefit applies), and that the making of a false statement or failure to comply with my duty of disclosure may invalidate my application > > if I fail to provide all or part of the information required, or where I have answered yes to a question in Step 3 and fail to consent to Hannover Life Re of Australasia obtaining such information as it requires, this application will not be assessed and processed > > at the date of this application I am not absent from work for reasons of illness or injury > > I have read the Member Guide PDS and the associated reference materials, I have read and understood the Duty of Disclosure and Non-Disclosure sections detailed below, and I have not withheld any information that may affect the Insurer s decision as to whether to accept my application. 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. 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 1800 640 886; > > 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.