Total Permanent Disablement Payment Request

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					                                                                     Total & Permanent Disablement
                                                                                  Payment Request
Savings & Loans Credit Union (AFSL 244310)
a division of Australian Central Credit Union (ABN 11 087 651 125)         Savings & Loans Retirement Savings Account
50 Flinders Street Adelaide SA 5000 Ph 13 11 82
                                                                                                     ABN 11 087 651 125
www.savingsloans.com.au



Application for the early release of superannuation as a total &
permanent disablement benefit
The Trustee of the Fund is responsible for ensuring that the benefits from the fund are paid in accordance
with legislation & the governing rules.

The Fund’s Trust Deed sets out a clear definition of Total & Permanent Disablement which is:
‘in the opinion of two independent medical practitioners, that you are unlikely ever to work again in a
position for which you are reasonably qualified by education training or experience’.


The trustees must be satisfied that your application meets the above definition before a benefit will be paid.


You will be required to complete the following forms:


     •     Withdrawal - Benefit Payment Request (FRM_0458) (to be obtained separately – please contact
           our office at the contact points mentioned below)
     •     Member Statement (enclosed)
     •     Two Independent Medical Certification forms (enclosed) #


# To be completed by two different Medical Practitioners/Specialists.


The Trustee will use this documentation to determine eligibility for early release of your superannuation
benefit.



For further information, contact Savings & Loans Superannuation on (08) 8305 8231 or email
super@savingsloans.com.au.

Please forward the completed paperwork to:
Savings & Loans Superannuation
GPO Box 463
ADELAIDE SA 5001




                                                                                                      V2 -1209-FRM_2212
                                                                                                              Member’s Statement

                                                                     Total and Permanent Disablement Claim
Savings & Loans Credit Union (AFSL 244310)
                                                                                            Savings & Loans Retirement Savings Account
a division of Australian Central Credit Union (ABN 11 087 651 125)                                                                  ABN 11 087 651 125
50 Flinders Street Adelaide SA 5000 Ph 13 11 82
savingsloans.com.au



                      Please answer the following questions fully and accurately.
  The following information will only be used to determine whether you fulfil the requirements
   for a claim of total and permanent disablement. This completed form (or copy) will not be
                   made available for any other purpose unless required by law.

    Name:

    Address:

    Date of Birth:

    Employment History (attach additional pages if necessary)
    (starting at most recently held position)

    start date                      finish date                         description of position                        name of employer
    (month & year)                  (month & year)

    from _________ to _____________ as ________________________________________

    from _________ to _____________ as ________________________________________

    from _________ to _____________ as ________________________________________


    Educational Qualifications (attach additional pages if necessary)

    Highest level of schooling completed:(please tick)
        primary school                   secondary school                   tertiary education

    List all educational qualifications:
    (include all trade certificates, diplomas and degrees)
    ...................................................................................................................................................
    ...................................................................................................................................................


    Language Skills
    Do you experience any difficulty in reading or writing English which would affect your ability to
    work in a job requiring you to read and write in English?
    .................................................................................................................................................

                                                                                                                              Please turn over

                                                                                                                                            V2 -1209-FRM_2212
                                                                          -2-


  Disability
  What is the nature of your disability?
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................
  How does your disability prevent you from working?
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................
  Please provide the names and addresses of doctors consulted for this disability.
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................
  Please describe your past and current medical treatment for this condition.
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................


  If there are any other factors of which you believe the trustee ought to be aware when making
  its decision, they should be noted here.
  .................................................................................................................................................
  .................................................................................................................................................
  .................................................................................................................................................




Signature: ......................................................................................             Date: ......................................


Please return this report to the following address:-




                                                Savings & Loans Superannuation
                                                         GPO Box 463
                                                      ADELAIDE SA 5001




                                                                                                                                          V2 -1209-FRM_2212
                                                     Independent Medical Certification

The Trustees
Savings & Loans Retirement Savings Account
50 Flinders Street
ADELAIDE       SA    5000


                      Savings & Loans Retirement Savings Account
                        TOTAL AND PERMANENT DISABLEMENT CLAIM


INDEPENDENT MEDICAL CERTIFICATION




Member’s full name:                  _____________________________________________

Member’s address:                    _____________________________________________
                                     _____________________________________________


Member’s date of birth:              ___/___/_____

Superannuation reference:            ______________


I hereby certify that the above-named person has been personally and independently examined
by me and is, in my opinion, disabled to such an extent that they are unlikely ever to work again in
a position for which they are reasonably qualified by education, training or experience.

This certification is independent of any other medical certification which may be provided in
respect of the above-named person, and is based on my personal investigations and consequent
opinion.


Signed:                                             Date:           /       / 200__


Name and qualifications:


Medical practice address:



                                                            __________________




                                                                                         V2 -1209-FRM_2212
                                                     Independent Medical Certification

The Trustees
Savings & Loans Retirement Savings Account
50 Flinders Street
ADELAIDE       SA    5000


                      Savings & Loans Retirement Savings Account
                        TOTAL AND PERMANENT DISABLEMENT CLAIM


INDEPENDENT MEDICAL CERTIFICATION




Member’s full name:                  ________________________________

Member’s address:                    ________________________________
                                     ________________________________


Member’s date of birth:              __/__/_____

Superannuation reference:            _________________


I hereby certify that the above-named person has been personally and independently examined
by me and is, in my opinion, disabled to such an extent that they are unlikely ever to work again in
a position for which they are reasonably qualified by education, training or experience.

This certification is independent of any other medical certification which may be provided in
respect of the above-named person, and is based on my personal investigations and consequent
opinion.



Signed:                                             Date:           /       / 200__


Name and qualifications:


Medical practice address:



                                                            __________________




                                                                                         V2 -1209-FRM_2212