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Standard Medical Examination Form

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					Standard Medical                                                                                                  Application Number


Examination Form
MLC Nominees Pty Limited (Trustee)           Trustee for The Universal Super Scheme     MLC Limited (MLC)
ABN 93 002 814 959                           R1056778                                   ABN 90 000 000 402 AFSL 230694
AFSL 230702 RSE L0002998                     ABN 44 928 361 101
To be completed by the Life to be Insured / Life Insured



 Part 1: Personal Statement by the Life to be Insured                            PART 1 PERSONAL STATEMENT BY THE LIFE TO BE INSURED
 Part 2: Confidential Medical Report to MLC Limited                             Name of Financial Adviser authorising examination
         for Insurance Cover

                                                                                Division               Financial Adviser No. Phone No.
 WHAT YOU MUST TELL US
                                                                                                                             (      )
 Your Duty of Disclosure
 Before you enter into a contract of life insurance with an insurer, you          Special instructions for the Medical Examiner
 have a duty, under the Insurance Contracts Act 1984, to disclose to the          (to be completed by the Financial Adviser)
 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              Resting ECG required                     Exercise ECG required
 the insurance and, if so, on what terms. You have the same duty to
 disclose those matters to the insurer before such a contract of life                   Please make particular comment on
 insurance is extended, varied or reinstated.
 Your duty, however, does not require a disclosure of a matter:
 • that diminishes the risk to be undertaken by the insurer;
 • that is of common knowledge;
                                                                                Personal statement made in connection with a proposal for
 • that your insurer knows or, in the ordinary course of business,              insurance on the life of:
   ought to‑know;                                                               Title           Surname (Family Name) (PLEASE PRINT)
 • for which your duty of compliance is waived by the insurer.
 If you take out MLC Life Cover Super the Trustee obtains life insurance        Given name(s)
 from MLC on you. Because the Trustee is taking out a life insurance
 policy at your request, the Trustee requires you to make full disclosure
 to it on the same basis.
                                                                                Address
 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                                                    Postcode
 avoid the contract at any time.
                                                                                Date of birth
 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 reduce the
 sum that you have been insured for in accordance with a formula that           Occupation and Industry
 takes into account the premium that would have been payable if you
 had disclosed all relevant matters to the insurer.
 Your Duty of Disclosure continues until the contract of life                   Occupational duties
 insurance has been accepted by the insurer and a policy is issued.
 It also applies if the contract is extended, varied or reinstated.




                                                                                  Complete sections A, B, C & D of the personal statement below in your
                                                                                  own words prior to the examination. The Medical Examiner will discuss
                                                                                  your answers with you and add any details considered appropriate.
                                                                                  Sign the declaration on page 4 in the Examiner’s presence.

                                                                                  The Medical Examiner is requested to ensure that a clear and
                                                                                  complete answer is given to each of the following questions.

                                                                                                 Standard Medical Examination Form Page 1 of 8
    A HABITS                                                                       B    MEDICAL HISTORY

1    a) Do you drink alcohol?                                                  If you answer ‘Yes’ to any item in this questions 3, 4, 5, 6 or 7,
                                                                               please give details at Question 10.
     No
                                                                               3       Do you have or have you ever had any of the following?
     Yes       Number of standard drinks:                                                                                                      Item
                           per day                    per week                                                                                 Code No   Yes
                                      or
                                                                                       Heart complaint, high blood pressure
                                                                                                                                               a
               Note: one standard drink = 1 glass of beer/wine/nip of spirit           or high cholesterol
                                                                                       Epilepsy or any neurological disorder                   b
	    b) If no, have you ever drunk alcohol?                                            Stroke or vascular disorder                             c
     No
                                                                                       Asthma or any other lung complaint                      d
     Yes       Number of standard drinks:                                              Diabetes, bowel, kidney or bladder disorder             e
                           per day    or              per week
                                                                                       Alcohol or drug dependence                              f
               Note: one standard drink = 1 glass of beer/wine/nip of spirit           Professional advice to reduce alcohol
                                                                                                                                               g
               Date ceased                  Reasons ceased                             consumption

                       /        /                                                      Migraine, persistent headache or chronic fatigue        h
                                                                                       Disorder of the reproductive system (eg prostate,
                                                                                                                                               i
                                                                                       ovary), or sexually transmitted disease
	2 a) Have you smoked tobacco or any other substance or used any                       Cancer or leukaemia                                     j
       nicotine‑containing product in the last 12 months?
                                                                                       Haemophilia or blood disorder                           k
     No
                                                                                       Liver disorder, hepatitis or test indicating past or
                                                                                                                                               l
     Yes       What type? eg cigarettes, gum, patch                                    present hepatitis infection
                                                                                       Any allergies, skin disorder, or disorder of the
                                                                                                                                               m
                                                                                       eyes, ears, nose or throat
               Daily quantity                                                          Cyst, mole or skin lesion requiring medical advice
                                                                                                                                               n
                                                                                       or treatment
                                                                                       Strained back, sciatica, whiplash, spondylitis or
                                                                                                                                               o
                                                                                       any other back, neck or spinal problem
                                                                                       Disorder of the joints or muscles, athritis, gout or
	    b) If no, have you smoked tobacco or any other substance or used any                                                                      p
                                                                                       repetitive strain injury
        nicotine‑containing product?                                                   Treatment or counselling for depression or any
                                                                                                                                               q
     No                                                                                nervous, anxiety, stress or mental health condition
                                                                                       Any other operation, disability, illness or injury,
     Yes       What type? eg cigarettes, gum, patch                                    medical investigation or test (eg genetic
                                                                                                                                               r
                                                                                       test, mammogram, ultrasound, ECG) not
                                                                                       already mentioned
               Daily quantity   Date ceased
                                                                               4       Other than already stated, have you in the last 5 years:
                                        /        /
                                                                                                                                               Item
               Reasons ceased                                                                                                                  Code No   Yes
                                                                                       Taken any prescribed medication on a regular or
                                                                                                                                               a
                                                                                       ongoing basis? (other than for colds or flu)
                                                                                       Used (by mouth, inhalation or injection) any drug
                                                                                       not prescribed by a doctor, other than medicines        b
                                                                                       purchased at a chemist?

                                                                               5       Do you NOW have any other disability, illness, injury
                                                                                       or symptoms not already mentioned?
                                                                               6       Do you contemplate seeking any advice, test,
                                                                                       investigation or treatment?
                                                                               	       Males:	Go	to	Question	10




Page 2 of 8 Standard Medical Examination Form
Females	Only                                                                       9    Have you ever had an abnormal pap smear?
7    Have you had any complications of pregnancy or childbirth?                         No             Yes        When?
     No          Yes            Give	details	at	Question	10

8    Are you currently pregnant?                                                                                  Treatment given
     No          Yes
                             Due Date                 /       /
                                                                                                                  Date and result of most recent pap smear




10 Did you answer ‘Yes’ to any item in questions 3, 4, 5, 6 or 7?
     No
     Yes       	 Give	full	and	accurate	details	below	of	each	instance.	
Question No. Disability, illness,                                                                             Have you
                                         Test        When did When did                             How long                     Name and address of medical
& Item Code injury, condition                                              Type of treatment                 completely
                                        results      it start? it cease?                           off work?                     facility and attending person
(see above)       or test                                                                                    recovered?




 C    FAMILY HISTORY

11 Have any of your parents, brothers or sisters (living or dead) suffered from any of the following?
     • Cancer (specify type and site)             • Diabetes                • Huntington’s disease                    • Familial polyposis
     • Heart disease                              • Kidney disease          • Motor neurone disease                   • Multiple sclerosis
     • Stroke                                     • Rheumatoid Arthritis    • Muscular dystrophy                      • Any other hereditary disorder
     No
     Yes          Please	provide	details	below


                                                                                                                                    Age condition Age at death
             Relationship                           Medical condition                          Cancer type and site
                                                                                                                                       began      (if applicable)




                                                                                                    Standard Medical Examination Form Page 3 of 8
 D DOCTORS DETAILS / LAST CONSULT                                               DECLARATION

12 What is the name and address of your usual doctor or medical centre?        Read	this	section	carefully	before	signing.
    (If no usual doctor, then the last doctor you last visited)                I understand and agree that:
      Doctor’s name or medical centre                                          a)   the answers to the questions in this Personal Statement are true and
                                                                                    complete and that this supplementary Personal Statement forms part
                                                                                    of my application for insurance;
      Address                                                                  b)   MLC is authorised to obtain any information from any medical
                                                                                    practitioner that they possess in relation to the insurance.
                                                                               Signature of Life to be Insured
                                            Postcode

      Business Number            (      )                                       ✗	                                                  Date     /      /


      How long have you been attending this practice?             yrs   mths   I declare that the signature of the Life to be Insured was signed in my
                                                                               presence and that I have discussed the personal statements made by
      Please provide details of your last check‑up or consultation.            the Life to be Insured where appropriate.
      Date of last consultation Reason for last check‑up or consultation       Signature of Medical Examiner
               /       /

      Result                                                                    ✗	                                                  Date     /      /



      Medication prescribed, referral given or tests ordered




Page 4 of 8 Standard Medical Examination Form
Standard Medical                                                                                                     Application Number


Examination Form
Part 2: Confidential Medical Report to MLC Limited for Insurance Cover

On the Medical Condition of
                                                                               MEASUREMENTS

                                                                               4   Give the following measurements:
Note: Information regarding your findings should NOT be given to any
other person. Exception may be made, subject to the examinee’s consent,             a) Height (without shoes)                                        cm
if in your opinion there is medical information which should be conveyed
to his/her medical attendant.                                                       b) Weight (clothed)                                              kg
The company’s decision concerning the proposal for insurance will be
                                                                                    c) BMI
based on a careful consideration of the medical evidence and other factors
including the type of insurance sought. The Examiner is therefore requested         d) Chest and abdomen at umbilicus (next to skin)
not to express to the examinee any opinion concerning the
examinee’s insurability.                                                                 Chest Expiration                                            cm

                                                                                         Chest Inspiration                                           cm
    INTRODUCTION
                                                                                         Abdomen                                                     cm
1    Are you aquainted with the examinee:
     a) Professionally?                                                        5   If chest expansion is less than 5 cm, comment as to the apparent cause
                                                                                   or provide peak flow meter reading if available.
     No
     Yes
                For how long?
                                                                               RESPIRATORY SYSTEM
	    b) Personally?
                                                                               6   Is there any abnormality of the respiratory system to palpation
     No                                                                            percussion or auscultation?
     Yes                                                                           No
                For how long?
                                                                                   Yes         Please give details

2    Is there anything unfavourable in appearance, development or behaviour?
     No

     Yes        Please give details


                                                                               7   Is there any sign of past or present respiratory disease?
                                                                                   No

                                                                                   Yes         Please give details

3    Is there any indication of past or present abuse of alcohol or the
     misuse of drugs?
     No

     Yes        Please give details




                                                                                              Standard Medical Examination Form Page 5 of 8
 CIRCULATORY SYSTEM
                                                                               14 Is there any abnormality of the peripheral arterial or venous circulation?
                                                                                   No
8   What is the rate and character of the pulse?
                                                                                   Yes        Please give details
    Pulse rate                         per minute

    Character

9   What is the position of the apex beat of the heart?

    In the                                          interspace          cm
                                                                               15 Do you consider the heart and the vascular system to be abnormal?
    from the mid‑sternal line                                                      No

10 Is there any evidence of cardiac enlargement?                                   Yes        Please give details
    No

    Yes          Please give details




                                                                               16 Is the examinee now on treatment for hypertension or
                                                                                   hypercholesterolaemia?
                                                                                   No
11 Is there any abnormality in the heart sounds or rhythm?
                                                                                   Yes        If known, please advise
    No
                                                                                              a) Pre‑treatment level including dates
    Yes          Please give details

                                                                                              b) Duration of treatment



                                                                                              c) Nature of treatment


12 Is there any murmur present?
    No
                                                                                DIGESTIVE AND LYMPHATIC SYSTEM
    Yes          Describe fully including site, timing, intensity and
                 transmission. Also indicate any effect of posture or
                 respiration on the murmur.                                    17 Is there any abnormality of tongue, mouth or throat?
                                                                                   No

                                                                                   Yes        Please give details




13 What is the Blood Pressure (auscultatory method)?
    The diastolic level is to be taken at the cessation of all sound. If the
    first systolic reading is above 135 or below 100, or the diastolic above   18 Is there any abnormality or evidence of disease of any abdominal organ,
    85 or below 60, two further readings at 5 to 10 minute intervals are           including liver or spleen?
    required. The recumbent position should be used where possible.
                                                                                   No
    Systolic                       Diastolic
                                                                                   Yes        Please give details
                      mm Hg                          mm Hg

    Systolic                       Diastolic
                      mm Hg                          mm Hg

    Systolic                       Diastolic
                      mm Hg                          mm Hg



Page 6 of 8 Standard Medical Examination Form
 DIGESTIVE AND LYMPHATIC SYSTEM CONTINUED                                 NERVOUS SYSTEM


19 Is there any abnormality of the lymph nodes in the neck, axillae or   24 Is there any defect of vision or abnormality of the eyes?
    inguinal regions?                                                        No
    No
                                                                             Yes        Please give details
    Yes        Please give details




                                                                         25 Is there any defect in hearing or speech?
20 Is a hernia present?                                                      No
    No
                                                                             Yes
    Yes        Please describe fully
                                                                             In case of present or past ear discharge or deafness, state result of
                                                                             auriscopic examination



                                                                         26 Is there any evidence of mental disorder?
                                                                             No

 GENITO-URINARY SYSTEM                                                       Yes        Please give details


21 Examination of the urine:
    The urine should be passed at the time of the examination. If not,
    please state the circumstances.
    If Albumin is found, an early morning specimen should be examined
    and findings recorded before completing the report.
                                                                         27 Is there any evidence of any disorder of the central or peripheral
    a) Albumin                                                               nervous system?
                                                                             No
    b) Glucose
                                                                             Yes        Please give details
    c) Blood

22 Is there any evidence of abnormality of the genito‑urinary system?
    No

    Yes        Please give details

                                                                          MUSCULOSKELETAL SYSTEM AND SKIN


                                                                         28 Is there any abnormality in the form or function of the joints, muscles or
                                                                             connective tissue?
                                                                             No
23 Females only                                                              Yes        Please give details
    Is the examinee pregnant?
    No
    Yes
               Expected date of confinement           /       /




                                                                                       Standard Medical Examination Form Page 7 of 8
 MUSCULOSKELETAL SYSTEM AND SKIN CONTINUED                                    Name of Medical Examiner (PLEASE PRINT)

29 Is there any abnormality in the form or function of the back or neck
    including the cervical and lumbar spine?                                  Qualifications
    No

    Yes        Please give details                                            Address



                                                                                                                          Postcode

                                                                              Telephone Number             (     )

                                                                              Signature of Medical Examiner
30 Is there any evidence of any disorder of the skin?
    No

    Yes        Please give details                                              ✗	
                                                                              Dated at                                          on          /        /

                                                                              Please indicate a GST Tax Invoice with your report to allow payment.


                                                                             Important
 SUMMARY                                                                     This Medical Examination is a matter of importance to the person you have
                                                                             just examined and it would be appreciated if you would forward the report
31 Do you consider any medical attendant’s report or any special tests are   without delay to:
    required? (No special tests are to be carried out in connection with     Mail
    the proposal for insurance without the company’s authority)              MLC Limited
    No                                                                       Attention: HNM
                                                                             PO Box 200
    Yes        Please give details                                           North Sydney NSW 2059
                                                                             Fax
                                                                             1800 550 081
                                                                             or if outside Australia on +61 2 9964 3163
                                                                             Email
                                                                             insurance_mlc@mlc.com.au
                                                                             (in TIF format only)*
32 Do you consider the person examined to be likely to require any           * Applications by email must have the Adviser name/number, application number
    surgical operation?                                                        and product type in the subject line of the email. Only one form can be sent via
                                                                               email even if your client is submitting two or more forms. An automatic response
    No                                                                         email will be sent to you once the email has been received.
    Yes        Please give details
                                                                             How to contact us
                                                                             MLC Client Service Centre
                                                                             For more information call the MLC Client Service Centre
                                                                             from anywhere in Australia on 132 652
                                                                             between 8 am and 6 pm EST, Monday to Friday
                                                                             or if outside Australia on + 61 3 8634 4721
33 Comment fully on any unfavourable features (either physical or mental)    or contact your financial adviser
    which could either reduce life expectancy or cause temporary or          Postal Address
    permanent disablement:                                                   MLC Limited
    a)    in the personal medical history                                    PO Box 200
                                                                             North Sydney NSW 2059
                                                                             Fax: 1800 550 081
                                                                             Website
                                                                             For details on MLC's range of products and services visit: mlc.com.au
    b)    disclosed by your medical examination
                                                                             OFFICE USE ONLY
                                                                              Amount                     Date                        Authorised
                                                                              $

                                                                                                                                                   05030 MLC 05/09
Page 8 of 8 Standard Medical Examination Form