Asgard Personal Protection Package/ Asgard Employee Super Account Individual Insurance Transfer Super Use this form if you are a current member of the Asgard Employee Super Account or Asgard Super Account (jointly referred to in this form as Asgard Super) and you wish to transfer your existing insurance cover with another superannuation fund or insurer to Asgard Super. Please read the Important information about Individual Insurance Transfer section prior to completing this form. This insurance cover through Asgard Super is offered by BT Funds Management Limited ABN 63 002 916 458 AFSL 233724 ( BTFM or the Trustee ) and AIA Australia Limited ABN 79 004 837 861 AFSL 230043 (the Insurer) is the issuer of this cover under the relevant Master Policy held by BTFM. Asgard Capital Management Ltd ABN 92 009 279 592 AFSL 240695 ( Asgard ) provides administration services in relation to this cover. Please refer to the relevant Product Disclosure Statement (PDS) for information on premiums and conditions: for Asgard Employee Super Account member Asgard Employee Super Account PDS for Asgard Super Account member Asgard Personal Protection Package PDS. If the Insurer accepts your application you will be allocated the same level of cover provided by your current fund/insurer subject to the underwriting terms provided by your current fund/insurer, including premium loadings, restrictions, exclusions or any other limitations applying to your current cover. If you hold multiple Asgard Employee Super accounts (AESA) under the one client number, the insurance request(s) being made in this form will be applied to your AESA account where you currently hold insurance cover. Your client number is the first 7 digits of your account number. To avoid any delay in your transfer request process, please ensure you: complete all sections, sign and date this form; attach an up-to-date statement from your current fund/insurer confirming the type, level and additional terms of your current insurance cover; and Send to us by either: email: applicationinsurance@asgard.com.au mail: Asgard Super, PO Box 7490, Cloisters Square WA 6850 fax: (08) 9481 4834 To transfer more than one insurance cover, please photocopy this form to provide all details relevant for each insurance cover being transferred. Please ensure you ve attached the required documentation for each of the insurance covers. Questions? Call us on 1800 998 185 or email asgard.investor.services@asgard.com.au i This symbol indicates you need to give us more information. 1. Account details Account number (for existing Asgard client only) D2 Title Surname Given name(s) Residential address (PO Box is not acceptable) Postal address (if different from residential address) State Postcode Email State Postcode Phone (home) Phone (business) 1 of 8 1 of 8
1. Account details (continued) Phone (mobile) Facsimile Date of birth Gender Occupation 1 Male Female Industry Smoker 2 1 Some occupations may be uninsurable and may be declined. Please refer to the financial adviser for your account for details. 2 You are a smoker if you have smoked tobacco or any other substance during the past 12 months. 2. Your current fund/insurer s details You should ask your current fund/insurer for information about the benefits of your current insurance cover including information on exit, transfer, withdrawal and other fees. You should do this so that you fully understand the effects of transferring your current insurance cover. Please tick the appropriate option below to indicate if you are transferring your insurance cover from a super fund or an insurance company. transferring my insurance cover from a super fund OR transferring my insurance cover from an insurance company Member account number Fund/Insurance company s name Fund/Insurance company s postal address Fund/Insurance company s telephone State Postcode Name of employer (if applicable) 2. I confirm the following details in relation to the cover that I am applying to transfer: (a) Life cover A$,, (maximum amount of cover you can transfer is $2 million) (b) TPD cover A$,, (maximum amount of cover you can transfer is $2 million) Please tick the type of TPD benefit below that you have in your current insurance cover. Standard Occupation (c) Salary Continuance Insurance cover I am permanently employed and working at least 15 hours per week, and physically capable of working 30 hours per week. Please tick the type of Salary Continuance cover below that you have in your current insurance cover. Indemnity Agreed value cover ** ** This option is only available to Asgard Super Account members. An additional premium will be applied to your Salary Continuance Insurance cover. In the event of a claim for an agreed value Salary Continuance Insurance benefit, we will require proof of income at the date of claim. If this amount is less than the amount stated on your acceptance certificate from your current fund/insurer, we may require financial proof of income from the start date of your current insurance cover. 2 of 8
2. Your current fund/insurer s details (continued) Salary Continuance Insurance cover (per month) A$, (maximum amount of cover you can transfer is $20,000 per month) Current Salary Continuance Insurance Waiting Period days (ie 30 days, 60 days, 90 days) Current Salary Continuance Benefit Period (ie 2 years or to age 65) I understand that the transfer of my current Life, TPD and Salary Continuance Insurance cover once accepted by the Insurer, will be subject to the terms and conditions of Asgard Super insurance arrangements with the Insurer and that my Salary Continuance Insurance benefit period and waiting period (if applicable) will be matched to the Asgard Super offer where possible. i For insurance cover held with another superannuation fund, you will need to attach your last annual statement from the fund (the statement must have been issued within the last 12 months of the date of the application. For insurance cover held with an insurer, you will need to attach an up-to-date statement letter or email from the insurer dated within 60 days from the date of the application form. This evidence must confirm the type and level of cover, or any loadings or exclusions currently held with the current fund/insurer. 3. Your personal statement and confirmation of requirements 1. Please confirm (by ticking one box below) that all of the following statements are true and correct: (a) My current insurance cover with my current fund/insurer is in force and has not lapsed; (b) I will cancel my current insurance cover with my current fund/insurer once I receive confirmation from Asgard that my Individual Insurance Transfer application has been accepted; (c) I will not be transferring my current insurance cover with my current fund/insurer to any other division or section of the current fund or to any other fund or insurer, other than Asgard Super; (d) After my current insurance cover has been cancelled, I will not apply for a continuation option or reinstate my cover with my current fund/insurer; (e) You are either, (i) gainfully employed & physically capable of undertaking gainful employment for at least 30 hours per week; or (ii) where you are not gainfully employed for reasons other than illness and injury and performing full time unpaid domestic duties in your own residence, you are physically capable of undertaking gainful employment for at least 30 hours per week. I confirm that all six statements are true and correct and agree to abide by these requirements If you answered you will not be eligible to transfer your current insurance cover from your current fund/insurer to Asgard Super. You are not required to complete the remaining sections of this form. 2. Are you currently absent from work or unable to carry out all of the duties of your current or usual occupation on a full-time basis, due to an injury or illness (even if you are not currently working on a full-time basis)? 3. Have you been paid, or are you eligible to be paid, or have you lodged a claim for a TPD/Salary Continuance Insurance benefit with another superannuation fund or life insurance policy? 4. Have you been diagnosed with an illness that reduces your life expectancy to less than 12 months from today? If you answered to any of the question 2 4 you will not be eligible to transfer your existing insurance cover from your current fund/insurer to BTFM. You are not required to complete the remaining sections of this form. 5. Is your cover under the current insurance cover subject to any premium loadings and/or exclusions including but not limited to pre-existing conditions, exclusions, or restrictions in regards to medical or other conditions. i If you answered please provide details of the premium loadings, exclusions and/or restrictions, including a copy of the advice you received from your current fund/insurer advising you of the acceptance of your cover subject to these additional terms. If any of your benefits from your current fund/insurer had more than two exclusions, or had a loading of more than +100% extra mortality, or had a combination exceeding 1 exclusion and +50% extra mortality, then cover for that benefit cannot be transferred. 3 of 8
4. Payment details Insurance premiums will be deducted from your Asgard Employee Super Account or Asgard Super Account on a monthly basis. 5. Adviser s details only to be completed for Asgard Super Account member Dealer name 111111111111111111111111111111111111 Adviser s name 111111111111111111111111111111111111 Adviser s phone (business) Mobile 11 1111 1111 1111 111 111 Asgard Adviser s code Adviser s email address 11111111BA 11 111111111111111111111111 Are there any applications being submitted simultaneously? 3 3 Adviser commission (including GST) 3 0% 3 5.5% 3 11% 3 16.5% 3 22% 3 27.5% For Asgard Super Account only (If not completed, new insurance policies will be set up with a commission rate of nil.) te: Adviser commission is not available on new insurance policies within Super in accordance with FOFA legislation, from 1 July 2014. Adviser commission is payable on new and existing standalone policies and increases to existing FOFA grandfathered policies within Super. Adviser s signature Date 11 11 1111 7. 6. Declaration and signature Duty of disclosure Before you enter into a contract of life insurance with an insurer, you have a duty under the Insurance Contracts Act 1984 to disclose to the insurer every matter that you know, or could reasonably be expected to know that is relevant to the insurer s decision whether to accept the risk of insurance and, if so, on what terms. You have the same duty to disclose those matters to the Insurer before you extend, vary, reinstate or transfer a contract of insurance. Any disclosure that you have, may have made or ought to have made at the inception of a contract of life insurance being extended, varied, reinstated or transferred must be made as part of your application for the Insurer to accept your application for cover. A transfer of an existing insurance cover does not release an applicant from the duty of disclosure under the Insurance Contracts Act 1984. n-disclosure and misrepresentation If you fail to comply with your duty of disclosure and the Insurer would not have entered into the contract on any terms if the failure had not occurred, the Insurer may avoid the contract within three years of entering into it. If your non-disclosure is fraudulent, the Insurer may avoid the contract at any time. An insurer who is entitled to avoid a contract of insurance may, within three years of entering into it, elect not to void it but to reduce the sum that you have been insured for in accordance with a formula that takes into account the contribution that would have been payable if you had disclosed all relevant matters to the insurer. Privacy Statement Why we collect your personal information We collect personal information (including sensitive information e.g. health information) from you to process your application, provide you with your product or service, and manage your product or service. 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 need to reject your application, or we may no longer be able to provide a product or service to you. 4 of 8
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. 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 1800 998 185. The Insurer s privacy policy is available at aia.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. These privacy policies 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. By signing this form I acknowledge that: I have been given a copy of the current PDS and any Supplementary Product Disclosure Statement (SPDS), as per confirmed by my financial adviser, which I have read and understood; if I do not fully complete, sign and date this Individual Insurance Transfer form, I will not be eligible to transfer my current insurance cover to Asgard Super; if the Insurer accepts my application, the cover I hold as at the transfer date with my current fund/insurer will be replaced with an equal amount of cover under Asgard Super but subject to a maximum of $2 million each for Life and TPD cover and $20,000 per month for Salary Continuance Insurance cover; 5 of 8
6. Declaration and signature (continued) my replacement cover will not commence in Asgard Super until the later of: the Insurer accepting my application; and cancellation of my current insurance cover with my current fund/insurer; The Insurer and any person appointed by the Insurer may undertake appropriate enquiries and investigations to verify the answers I have provided; Asgard, the Trustee and the Insurer may investigate whether any premium loadings, restrictions and exclusions apply to your current insurance cover; I agree to provide Asgard, the Trustee or the Insurer with access to the health and/or financial evidence I provided to any current fund and their insurer or retail insurer in an application for the cover. Any non-disclosure to a current fund/insurer may be acted upon by Asgard, the Trustee or their insurer, and should it become apparent to Asgard, the Trustee or the Insurer that I have not responded truthfully or satisfied the requirements that I confirmed in Section 4 above, then any insured benefit that may be payable may be reduced by the insured amount paid or payable by my current fund otherwise; or any other fund or retail insurance arrangement; or any policy issued under any option that I exercised, as a consequence of my failure to abide by these conditions; I authorise the Insurer to disclose personal medical information and any other information gathered in relation to this application to my financial adviser and any other entity involved in the administration of this insurance, including reinsurers, medical consultants and legal advisers; I hereby declare that the information contained in this Individual Insurance Transfer form (whether written in my hand or not) is true and correct and that no information material to this application for transfer has been withheld; if the Insurer accepts my application, my replacement cover will be held upon and subject to the terms and conditions of the relevant Master Policy of insurance held by the Trustee and the terms and conditions applying to my cover through my current fund/insurer will cease to apply; I understand that the Trustee is the owner of the relevant Master Policy effected with the Insurer and that I will become a Life Insured under that Master Policy; I have read the Duty of Disclosure notice and understand its contents and what is meant by my duty to disclose. I also understand that my duty to disclose continues after I have completed this application for transfer until the Insurer has accepted the risk; I understand that, if the amount of my total Life and Total and Permanent Disablement insurance cover is currently calculated based on factors such as salary or age (and may increase or decrease accordingly), the amount of cover provided under Asgard Super will convert to a fixed sum insured; I acknowledge that premiums are paid to, and my replacement cover and benefits provided in the relevant Master Policy are liabilities of the Insurer. Premiums are not deposits in, nor liabilities of, and not guaranteed by any bank or company whether related to the Insurer or not; I authorise the Administrator to deduct the premiums and charges for this insurance from my Account, retain the Administration fee and pay the balance on my behalf to the Insurer. I agree to receive any communications (including any confirmation of any transaction, dealing, notice of material changes and significant events and other information I may request) and documents (including periodic reports) which Asgard, the Trustee or the Insurer is or may be required to give, or has agreed to give, to me relating to my Account via Investor Online, or any other electronic means chosen by Asgard, the Trustee or the Insurer (and for these purposes, I agree I will be taken to have received the relevant information whether or not I access the information). I acknowledge my replacement cover may become void if my current insurance cover has lapsed with my current fund/insurer before the Insurer accepts my application. Signature of Life Insured Date 6 of 8
Important information about Individual Insurance Transfer The Insurer agrees to provide individual transfer terms for your current insurance cover with another superannuation fund or insurer on the following basis. My additional cover may become void if my current insurance cover has lapsed with my current fund/insurer before the Insurer accepts my application. The maximum amount of cover that can be transferred is: $2 million each for Life and Total Permanent Disablement (TPD). $20,000 per month for Salary Continuance Insurance. The waiting period (WP) and benefit period (BP) will be matched to Asgard s insurance offer. If your current WP is different, the WP for your replacement cover will be rounded up to the next longest WP offered by Asgard, ie a 45 day WP will be rounded up to a 60 day WP in the insurance cover. For BP, you will receive the equivalent of your current BP, or if not available in the insurance cover, the lesser BP offered in the replacement insurance cover. The level of cover provided to you will be the level of cover currently held through your current fund/insurer and only where the current insurer s acceptance terms were less than or equal to two exclusions, or had a loading of less than or equal to +100% extra mortality, or had a combination less than or equal to 1 exclusion and +50% extra mortality. For Life/TPD and Salary Continuance Insurance cover, if an exclusion is transferred from your current fund/insurer, the exclusion wording of the relevant Asgard PDS will apply. The current cover held through your current fund/insurer ( current fund/insurer refers to another retail insurer which you intend leaving) or current insurance cover ( current insurance cover refers to any external retail insurance arrangement you might intend cancelling) ceases on acceptance of cover in Asgard Super. You have not received nor are eligible for a TPD or Salary Continuance Insurance benefit from another insurance arrangement. You are not terminally ill with a life expectancy of less than 12 months. You must meet one of the following criteria: You are gainfully employed and physically capable of undertaking gainful employment for at least 30 hours per week; or Where you are not gainfully employed for reasons other than illness and injury and performing full time unpaid domestic duties in your own residence, you are physically capable of undertaking gainful employment for at least 30 hours per week. For Salary Continuance Insurance cover, you are permanently employed and working at least 15 hours per week, and physically capable of working 30 hours per week. You must be under the age of 65 at the date of application. You must meet the eligibility criteria for insurance cover as set out in the APPP PDS. You do not continue the cover under another insurance arrangement. You provide a copy of an up-to-date statement, letter or email produced by the current fund/insurer dated within the last 60 days, as evidence of cover currently held with the current fund/insurer. Your replacement cover will not commence in Asgard Super until the later of: the Insurer accepting your application, and the existing insurance cover with the current fund/insurer being cancelled. You complete this Individual Insurance Transfer form to the Insurer s satisfaction. Occupational classifications will be based on the classifications used by Asgard Super. Ratings and premiums may change to adapt to Asgard s ratings and premiums. 7 of 8
TRUSTEE BT Funds Management Limited ABN 63 002 916 458 AFSL 233724 RSE L0001090 ADMINISTRATOR Asgard Capital Management Ltd ABN 92 009 279 592 AFSL 240695 Customer Relations 1800 998 185 PO Box 7490, Cloisters Square WA 6850 AS30503_0714ex 8 of 8