Death Claim Information Form 1 March 2013 OnePath MasterFund ABN 53 789 980 697 RSE R1001525 SFN 292916944 OnePath Custodians Pty Limited ABN 12 008 508 496 AFSL 238346 RSE L0000673 347 Kent Street, Sydney NSW 2000 ANZ Smart Choice Customer Services Phone 13 12 78 Email ANZSmartChoice@anz.com Postal address Please return completed forms to: ANZ Smart Choice Customer Services, Reply Paid 85728, Sydney NSW 2001. Please note This form must be completed in full to enable processing of your claim. Please attach a separate sheet if you require more room for a particular answer. Membership Number(s) Name of Deceased Surname Given name(s) Residential Address State Date of Death (dd/mm/yyyy) Age Last Birthday Occupation Cause of Death Postcode Duration of Illness Marital Status at the Date of Death Please select the option/s that best describe the Member s marital status at the time of death: 1. Married... 2. Divorced... 3. In a de facto relationship... 4. Widowed... 5. Permanently separated from spouse or de facto partner... 6. Never married and never in a de facto relationship... Relationship History If you did not select option 6 for the Member s marital status at the time of death, please provide full details of all of the Member s spouses and de facto partners throughout their life, not just the partner at the time of death Name (please include the name of the deceased partners where applicable) For example: Jan Jones Nature of Relationship Address Date of Marriage or Cohabitation (mm/yyyy) Date of Divorce or Permanent Separation (if applicable) (dd/mm/yyyy) Ex Spouse 1 Same St, Island Town 1234 01 / 1935 01 / 1948 Mary Sample Spouse 2 Bea Rd, Anytown 1357 01 / 1950 / / / / / / / / 1 of 8
State of Affairs at the Time of Death Please answer the following questions regarding the state of the Member s affairs at the time of death: 1. Did the Member pass away leaving a Last Will and Testament?... Yes No 2. If you answered yes to question 1, will a Grant of Probate be sought?... Yes No 3. If you answered no to question 1, will Letters of Administration be sought?... Yes No Dependants at the Time of Death A Dependant includes the Member s spouse (including de-facto spouse), all children (including step, adopted, ex-nuptial and posthumous natural children) regardless of a child s age and financial situation, and any person who was wholly or partially interdependent on the Member. If there are no Dependants then please write Nil across this section. Please list all of the Member s Dependants who were alive at the time of the Member s death. Dependant Name Age Name of Custodian or Guardian Address For example: Mary Sample 72 1 Same St, Island Town 1234 Paul Citizen 38 2 Bea Rd, Anytown 1357 Relationship to Member Widow Yes Step Child No Financial Dependant? Document Checklist To determine what documents are necessary, please complete the following checklist. Please ensure you attach certified copies of all required documents. Document When required Attached? 1. Member s Death Certificate: Required in all cases as a proof of Member s death. 2. Member s Birth Certificate or Passport: Required in all cases as a proof of Member s age. 3. Evidence of Name Change: Required where the member had a name change. 4. Last Will and Testament: Required if the Member left a Last Will & Testament 5. Grant of Probate or Letters of Administration: Required where either of these items has already been obtained. 6. Complete list of Assets and Liabilities: Required where there is a Legal Personal Representative of the estate. Details of the Person completing this form Surname Given name(s) Residential Address State Postcode Relationship to deceased Telephone Number 2 of 8
Declaration I, (Name) of (Address) hereby declare that I am over 18 years of age and that I may be legally entitled to claim the proceeds of the said policy/ies, being the * of the Deceased, and hereby undertake to indemnify the Trustee against any loss it may incur in paying the proceeds to me, should I be called upon to do so, and that the particulars which are given above are true and correct in every particular. * Here state in what capacity you claim, whether as Father, Mother, Widow, Widower, or other relation, or as Proponent, Assignee, Trustee, Beneficiary, Executor, or Administrator of the Estate, etc. I acknowledge that I have read, understood and agree to the Privacy Information and Consents contained in this form. I accept that the collection, use and disclosure of my personal information is necessary for the purpose of administering my claim. I understand that OnePath will not be able to process my claim without this information. Signature of Claimant 7 Date (dd/mm/yyyy) Signature of Witness 7 Date (dd/mm/yyyy) Name of Witness (Please print name) Occupation Signature to be witnessed by anyone who is prescribed as being able to witness a Statutory Declaration under the Commonwealth Statutory Declaration Act 1959. For example, Australia Post employee, Bank Officer (both must have 5 years continuous service), Justice of the Peace or legal practitioner, except when signed in the presence of an Officer of the Trustee. Privacy Information and Consents We are committed to ensuring the confidentiality and security of your personal information. The OnePath Privacy Policy detailing our handling of personal information is available on request. You may request access to the information held by us about you, your polic(ies) and any other OnePath related products or services which you may hold by contacting the OnePath Privacy Officer. In order to undertake the management and administration of your claim, it may be necessary for us to disclose your personal information to certain third parties. Unless you consent to such disclosure we will not be able to consider the information you have provided. The types of organisations to whom we may routinely disclose your personal information include: organisations undertaking compliance reviews of our financial advisers; organisations undertaking reviews of the accuracy and completeness of our information; organisations maintaining our information technology systems and providing information technology services; organisations providing mailing services; organisations undertaking assessment of claims; reinsurance organisations for the purpose of underwriting your application and assessing claims. We will only disclose your personal information to these organisations for the provision by them of certain specified management and administration services. Where you wish to authorise any other parties to act on your behalf, to receive information and/ or undertake transactions please notify us in writing. 3 of 8
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Withdrawal Form 1 March 2013 OnePath MasterFund ABN 53 789 980 697 RSE R1001525 SFN 292916944 OnePath Custodians Pty Limited ABN 12 008 508 496 AFSL 238346 RSE L0000673 347 Kent Street, Sydney NSW 2000 ANZ Smart Choice Customer Services Phone 13 12 78 Email ANZSmartChoice@anz.com Postal address Please return completed forms to: ANZ Smart Choice Customer Services, Reply Paid 85728, Sydney NSW 2001. 1. Member number(s) Member number(s) 2. Name of applicant Surname Given names(s) Current address Date of birth (dd/mm/yyyy) State Office hours phone number Postcode 3. Direct Credit Facility Payments will be credited directly to your Bank/Building Society/Credit Union account. Please provide your full details below. NB: Direct crediting may not be available on a full range of account types. Please check with your financial institution. Name of Bank/Credit Union/Building Society Account Holder s Name Bank (BSB Number) Account number 4. Tax File Number (TFN) Notification Your Tax File Number Information you should know about providing your Tax File Number The collection of tax file numbers is authorised by tax laws, the Superannuation Industry Supervision Act 1993 and the Privacy Act 1988. OnePath is authorised to collect members tax file numbers on behalf of the Trustee of the Fund (OnePath Custodians Pty Limited ABN 12 008 508 496 AFSL 238346 RSE L0000673). The purposes for which your tax file number is currently authorised to be used include: taxing Eligible Termination Payments at concessional rates; finding and amalgamating your superannuation benefits where insufficient information is available; passing your TFN to the Australian Taxation Office (ATO) where you receive a benefit or have unclaimed superannuation money after reaching the aged pension age; allowing the trustee of your superannuation fund or the provider of your Retirement Savings Account to provide your TFN to another superannuation provider receiving any benefits you may transfer. Your trustee or superannuation provider won t pass your TFN to any other provider if you tell them in writing that you do not want them to pass it on; allowing your superannuation provider to quote your TFN to the ATO when reporting information for the purposes of the Superannuation Contributions Tax (Surcharge). 5 of 8
You are not required to provide your TFN. Declining to quote your TFN is not an offence. However, if you do not provide it: you may pay more than you have to on your superannuation benefits (you will get back at the end of the financial year in your income tax assessment); it may be more difficult to find your superannuation benefits if you change your address without notifying your fund or to amalgamate any multiple superannuation accounts; the Superannuation Contributions Tax (Surcharge) may apply to certain contributions and transfers to your superannuation fund; The lawful purposes for which your TFN can be used and the consequences of not quoting your TFN may change in future, as a result of legislative change. Further information is also available from the ATO Superannuation Helpline on 131 020. 5. Declaration I, (Name) of (Address) hereby declare that I am not bankrupt or insolvent under administration and that the information provided by me in this form is true and correct. I request that the Trustee, OnePath Custodians Pty Limited ABN 12 008 508 496 to act upon and give effect to the directions given by me in this notice. I acknowledge that should I, or my estate receive a payment from OnePath Custodians Pty Limited in full satisfaction of my benefits under the Policy and/or the Fund, OnePath Custodians Pty Limited would have fully discharged their obligations under the Trust Deed governing the Fund and the Policy, and that any payment made to or in respect of me shall be net of the lump sum tax paid, as required by law, to the Australian Tax Office. Signature of Claimant 7 Date (dd/mm/yyyy) Signature of Witness 7 Date (dd/mm/yyyy) Name of Witness (Please print name) Occupation Signature to be witnessed by anyone who is prescribed as being able to witness a Statutory Declaration under the Commonwealth Statutory Declaration Act 1959. For example, Australia Post employee, Bank Officer (both must have 5 years continuous service), Justice of the Peace or legal practitioner, except when signed in the presence of an Officer of the Trustee. 6 of 8
Know your customer identification requirements Please send in certified copies* (not originals) of the following: one primary photographic identification document or one primary non-photographic identification document and one secondary identification document. Please note: we cannot accept certified copies by fax. Acceptable forms of identification Primary photographic identification document Current Australian or foreign driver s licence Australian passport (current or expired less than 2 years ago) Foreign government issued passport that also contains the holder s signature Proof of Age document issued by a State or Territory Foreign government issued identity card containing the holder s signature Primary non-photographic identification document Australian birth certificate Certificate of Australian citizenship Foreign government issued birth certificate Foreign government issued certificate of citizenship Centrelink pension or health care card Secondary identification document Commonwealth, State or Territory government issued document showing name and residential address and the provision of financial benefits Tax Office issued document showing name and residential address and an amount payable that was issued within the preceding12 months Local government or utility issued document showing name and residential address and the provision of services that was issued within the preceding 3 months. If under the age of 18, a notice from a school principal containing the name and residential address and the period of attendance at that school that was issued within the preceding 3 months. Documents not in English must be accompanied by an English translation prepared by an accredited translator. * A certified copy is a document that has been certified as a true copy of the original by one of the following: a person enrolled on the roll of a Supreme Court or the High Court as a legal practitioner a judge, registrar or deputy registrar of a court a magistrate a chief executive officer of a Commonwealth court a justice of the peace a notary public a police officer an agent of Australia Post in charge of supplying postal services to the public a permanent employee of Australia Post with 2 years continuous service employed in supplying postal services to the public an Australian consular or diplomatic officer an officer with 2 years continuous service with one or more financial institutions a finance company officer with 2 years continuous service with one or more finance companies an officer or authorised representative of an AFSL holder with 2 years continuous service a member of the Institute of Chartered Accountants in Australia, CPA Australia or National Institute of Accountants with 2 years continuous membership. NB The person who is authorised to certify documents must 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 the Peace, Australia Post employee, etc) and date. 7 of 8
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