Application to increase Income Protection cover due to salary increase by lindahy

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Application to increase Income Protection cover due to salary increase

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									        Application to increase Income Protection
        cover due to salary increase
         Please complete in pen using BLOCK letters. Print ‘X’ to mark boxes where applicable. This form must be completed by both you and
         your employer.
         If you already have Income Protection (IP) cover you may be eligible to                If this form is not received by the Finsuper division within the required
         increase your level of IP units (up to 20) to ensure cover remains in line             time, your request for additional cover will not be accepted on this form.
         with your salary. Part A of this form must be completed along with one
                                                                                                Restriction in unit increases:
         of the following:
         • Part B attached to this form; or                                                     • standard iP (benefit payment period up to two years) – use this form
                                                                                                    to apply for any increase of units, up to a maximum of 20 units.
         • A copy of your previous and new payslip with details of your new
             salary and the effective date; or                                                  • long-term iP (benefit payment period up to age 65 years) – use this
                                                                                                    form to apply for a maximum increase of two units for any one salary
         • A copy of the letter of your salary increase from your employer or a                     increase, up to a maximum of 20 units.
            notice from the employer or union announcing an across the board
            pay increase.                                                                       To increase more than two units of Long-term IP or above 20 units
         For this offer to be valid the above documentation must be received                    (for both standard and long term IP), complete the Application to vary
         by the Finsuper division within one month of the effective date or                     insurance cover form which includes a Personal health Statement. Please
         the notification date of your salary increase, whichever is the latter.                refer to the Member Guide (PdS) for further details or call 1300 300 273.

            PART A – memBer DeTAILS (To Be coMPLeTed By The MeMBer)
         Surname                                                                                                                     Mr       Ms Mrs Miss dr         other
                                                                                                                                      X       X      X   X       X
         Given names                                                                                                                 date of birth
                                                                                                                                      D       D m m          Y   Y    Y       Y
         Street address


         Suburb                                                                                                                      State                Postcode


         Telephone (Bh)                                            (Ah)                                                     Mobile


         email (optional)                                                                                                            Age                 Male         Female
                                                                                                                                                          X               X
         occupation                                                                                                         Membership number


         duties performed



            New COver requIreD
         Below is a guide indicating the number of units you will require for each salary range:

                                                 Number                                                              Number
           Your annual salary                                     Your annual salary
                                                 of units                                                            of units
             X Up to $7,057 pa                        1            X $70,589         –   $77,647 pa                    11             For permanent, part-time
                                                                                                                                      and contract workers, annual
             X $7,058        – $14,117 pa             2            X $77,648         –   $84,705 pa                    12
                                                                                                                                      earnings are your salary (before
             X $14,118 – $21,176 pa                   3            X $84,706         –   $91,764 pa                    13             tax, including fringe benefits
                                                                                                                                      taken in lieu of cash payments).
             X $21,177 – $28,235 pa                   4            X $91,765         –   $98,823 pa                    14             casual workers will need to
                                                                                                                                      estimate their annual earnings.
             X $28,236 – $35,294 pa                   5            X $98,824         –   $105,882 pa                   15
                                                                                                                                        Make sure you clearly indicate
             X $35,295 – $42,352 pa                   6            X $105,883 –          $112,941 pa                   16               the total units you require
             X $42,353 – $49,411 pa                   7            X $112,942 –          $120,000 pa                   17               by placing a mark (x) in the
                                                                                                                                        corresponding box.
             X $49,412 – $56,470 pa                   8            X $120,001 –          $127,058 pa                   18
                                                                                                                                               Please send me the
             X $56,471 – $63,529 pa                   9            X $127,059 –          $134,117 pa                   19                 X
                                                                                                                                               relevant forms to apply
             X $63,530 – $70,588 pa                  10            X $134,118 –          $141,176 pa                   20                      for cover above 20 units.

                                                                   X Salaries $141,177 pa and above                   >20

         *if your salary is greater than $141,177 per annum, or if you have long-term income Protection cover and wish to increase more than two units due to a
         salary increase, you will need to complete the finsuper Division Application to vary insurance cover form which includes a Personal Health statement.
         income Protection insurance allows you to cover up to 85% of your salary. Any benefit in excess of 75% of your pre-disability salary, up to a maximum of
         10%, will be paid to your finsuper Division account as an undeducted contribution. This means that in the event of an injury or illness, where you may
         be off work for a few months, you can continue to grow your superannuation savings while receiving an income Protection benefit.


                                                                                                        Office use Only
                                                                                                        Membership number



Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 the Trustee of AustralianSuper ABN 65 714 394 898                                               10322 06/09      page 1 of 4
       Duty of disclosure
       Before you enter into or become insured under 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, 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 renew, extend,
       vary or reinstate a contract of life insurance.
       your duty does not require disclosure of a matter:
       •       that diminishes the risk to be undertaken by the insurer;
       •       that is of common knowledge;
       •       that your insurer knows, or in the ordinary course of its business, ought to know; or
       •       as to which compliance with your duty is waived by the insurer.

       Non disclosure
       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 life insurance may, within three years of entering into it, elect not to avoid
       it but to reduce the sum that you have been insured for in accordance with a formula that takes into account the premium that would have been
       payable if you had disclosed all relevant information to the insurer. your duty of disclosure continues until the contract of life insurance has been
       accepted by the insurer and confirmation in writing issued.
       Please note: you must complete, sign and date Part A of the application in full and, if required, arrange for your employer to complete Part B of the
       application before returning to:
           AustralianSuper Finsuper division
           GPo Box 1901, Melbourne VIc 3001
       If you have any questions or require assistance to complete the form, please call AustralianSuper on 1300 300 273.

           DeCLArATION
       i declare that
       • all answers provided by me on this form are true and correct.
       • I have read and understand the duty of disclosure and Non-disclosure sections above and I have not withheld any information that may affect
               the Insurer’s decision as to whether to accept my application for increased cover.
       • I am currently employed and am able to carry out all of the identifiable duties of my employment without restriction due to injury or illness,
               on a full time basis.
       furthermore
       • I acknowledge that if I do not complete this application correctly, or I do not sign and date this form, my previous election will remain in force.
       • I acknowledge that insurance cover will only be provided on the terms and conditions set out in the contract of insurance with AustralianSuper’s
               insurer and as agreed between AustralianSuper and its insurer from time to time.

       Applicant to sign here:

       your signature                                                                                                       date
                                                                                                                            D      D m m   Y    Y    Y    Y


       Disclaimer: AustralianSuper and its representatives can only provide general financial product advice with regards to superannuation. This means
       that this document has been prepared without taking into account your personal needs, circumstances and objectives. you should assess your own
       financial situation and read the relevant Finsuper division member documentation, such as the Member Guide, which is the Product disclosure
       Statement (PdS) for AustralianSuper Finsuper division before making any decisions about your insurance cover. If you have any doubt about
       choices you have in Finsuper division, we recommend that you seek appropriate advice from a professional financial adviser.




       Office use Only:
       Previous level of cover                                                               Application approved


       New level of cover requested                                                          Application declined


       Notification/effective date of salary increase                                        date
           D      D m m           Y    Y   Y    Y                                             D     D m m           Y   Y    Y     Y




Please return this completed form to AustralianSuper GPO Box 1901 melbourne vIC 3001
Telephone 1300 300 273 Fax 1300 366 273 Web www.australiansuper.com
                                                                                                                                                          page 2 of 4
        Application to increase Income Protection
        cover due to salary increase (cont)

           PART B – EmPloyER dETAils (To Be coMPLeTed By The eMPLoyer)
        Members of the Finsuper division who already have Income Protection (IP) cover may be eligible to increase their level of cover (up to 20 units)
        to ensure cover remains in line with their salary provided they do so within one month of the effective or notification date of their new salary,
        whichever is the latter.
        If this form is not received by the Finsuper division within the required time, the member’s request for additional cover will not be accepted on
        this form. Please assist the member by completing and returning this form to them promptly.

           PerSONAL DeTAILS
        Surname                                                                                                                 Mr      Ms Mrs Miss dr              other
                                                                                                                                X       X       X       X       X
        Given names                                                                                                             date of birth
                                                                                                                                 D      D m m               Y   Y    Y      Y

           emPLOYer DeTAILS
        employer trading name                                                                                          employer ABN


        Address


        Suburb                                                                                                                  State                   Postcode


        Telephone (Bh)                                             (Ah)                                                Mobile


        email


        Name of person completing this form


        Position of person completing this form                                                                        Finsuper division employer number



           SALArY DeTAILS
        your salary (per annum)                                    effective date of new salary:                     Notification date of new salary:
                                                                     D     D m m            Y     Y     Y    Y        D    D m m            Y       Y       Y   Y

           emPLOYer’S DeCLArATION
        i declare that
        • all answers provided by me on this form are true and correct.
        • this member is currently employed by the employer noted above.

        Signature                                                                                                               date
                                                                                                                                 D      D m m               Y   Y    Y      Y




        Please return this completed form to AustralianSuper GPO Box 1901 melbourne vIC 3001
        Telephone 1300 300 273 Fax 1300 366 273 Web www.australiansuper.com




Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 the Trustee of AustralianSuper ABN 65 714 394 898                                                          page 3 of 4
                                                This page has been left blank intentionally.




Please return this completed form to AustralianSuper GPO Box 1901 melbourne vIC 3001
Telephone 1300 300 273 Fax 1300 366 273 Web www.australiansuper.com
                                                                                               page 4 of 4

								
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