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FUNERAL iNsURANcE
At MBF
Product Disclosure Statement
1 January 2011
cONtENts
About this Product Disclosure Statement
Summary of benefits 2
What is Funeral Insurance at MBF? 3
About your premiums 7
Easy steps to applying for Funeral Insurance at MBF 10
About this Product Disclosure Statement Additional Information about Funeral Insurance at MBF 11
This Product Disclosure Statement (PDS) has been
prepared to help you make an informed decision about Privacy and your personal information 17
Funeral Insurance at MBF. Any advice in this PDS is
general advice only and does not take into account your Your duty of disclosure 20
individual financial situation, needs or objectives. You
should consider this PDS before making any decision Definitions 21
about whether to hold or acquire this product.
Your application for insurance is subject to acceptance by
ClearView Life Assurance Limited.
This PDS has been prepared with the most up-to-date
information available at the time of production.
In the event of an omission of information or if there is a
materially adverse change to the information, ClearView
Life Assurance Limited will issue a supplementary or
replacement PDS.
Information that is not materially adverse is subject to
change from time to time. More up-to-date information
may be available by visiting our website at mbflife.com.au
We will give you a paper copy of any updates (free of
charge) if you request them.
Many of the terms/words used in this document have
specific meanings. These words are italicised and their
meanings are explained in the Definitions section. You
should consult this section and understand the definitions
prior to making any decision in relation to this product.
In this PDS ‘you’ refers to the Policy Owner and/or the Life
Insured, as the context requires, and ‘we/us/our/insurer’
refers to ClearView Life Assurance Limited. ClearView Life
Assurance Limited is a company within ClearView.
Funeral Insurance at MBF is issued by ClearView Life
Assurance Limited. Bupa Australia Pty Limited and Bupa
Australia Health Pty Ltd do not underwrite or in any way
guarantee Funeral insurance at MBF or any financial
advice provided.
Funeral Insurance at MBF
Product Disclosure Statement 1 January 2011
This is an important document and should be kept in a safe place.
Issued by: ClearView Life Assurance Limited ABN 12 000 021 581
AFS Licence No. 227682
1
Benefits Funeral Insurance
FUNERAL iNsURANcE WHAt is FUNERAL
At MBF iNsURANcE At MBF?
Summary of Benefits Funeral Insurance at MBF offers valuable life
insurance protection
Death Benefit*
Funeral Insurance at MBF is designed to pay a
Terminal Illness Benefit lump sum benefit in the event of your death or
being diagnosed with a Terminal Illness. This cover
Choice of cover, ranging from $5,000 to $50,000 is world wide, 24 hours a day.
Guaranteed acceptance, regardless of health
Why insure your life under Funeral Insurance
24 hour worldwide protection at MBF?
Cover automatically increases each year The lump sum benefit payable under Funeral
to keep pace with Inflation Insurance at MBF can be of enormous help to
your loved ones, ensuring they are not left with
Death benefit is doubled if death is the a financial burden in the event of your death or
result of a Motor Vehicle Accident Terminal Illness.
Increased discounts the longer you hold For example, you may want to provide money to
your cover settle some small debts or simply cover the cost
Premiums waived from age 90 of your funeral (which can be several thousand
dollars). Whatever the reason, you will find that
Funeral Insurance at MBF offers simple, affordable
life insurance.
PLUs … Additional benefits for
MBF Health insurance Members Who can apply for Funeral Insurance at MBF?
Provided you are a Permanent Australian Resident
10% discount on premiums aged 18 – 75 (inclusive) at the time of applying for
Funeral Insurance at MBF, we guarantee to accept
An extra 10% paid on all claims
your application for cover, no matter the state of
Private health insurance premium waiver your health.
in the event of Terminal Illness There are no complicated forms or health
questions to answer, enabling people with existing
* Limited to Accidental Death in first 2 years. health issues to obtain valuable cover.
2 3
What are the benefits and when are Cover Indexation Benefit
they payable?
Each year upon the Policy Anniversary, we will
When you apply for cover, you select the Sum automatically increase your cover to keep your
Insured. The amount selected must be in multiples insurance in line with Inflation. This benefit
of $5,000 and is subject to the minimum and can help your level of cover to keep pace with
maximum guidelines in the table below. inflationary increases for the costs you are trying
to cover, such as the cost of a funeral.
Age at Application Minimum Maximum
The amount of the increase will be the greater
18 - 54 $10,000 $50,000 of the Consumer Price Index (CPI) and 5%, and
premiums will be adjusted accordingly for this
55 - 75 $ 5,000 $50,000 valuable increase in cover.
During the first 24 months of the Policy, the Sum The Cover Indexation Benefit will cease to be
Insured will only be paid if you die as a result of offered from the Policy Anniversary after the Life
an Accident. This is referred to as the Accidental Insured turns age 90. Up until this time, you may
Death Only Period. After that period, the Sum opt in or out of the Cover Indexation Benefit by
Insured will be paid if you die from any cause or notifying us in writing at least 30 days before your
become Terminally Ill. next Policy Anniversary.
If you increase the Sum Insured, the Accidental Motor Vehicle Accident Double Benefit
Death Only Period will apply to the amount of the If the Life Insured dies as a result of a Motor
increase. Vehicle Accident, we will double the Sum Insured
If your Policy is reinstated, the Accidental paid.
Death Only Period will restart from the date of This benefit will only be paid if:
reinstatement.
• the Life Insured dies as a result of an Accident
If you die from any cause other than an Accident in which the Life Insured was a passenger or
during the first 24 months and no claim is paid, the driver of a Motor Vehicle;
we will refund the premiums you have paid on the
Policy. This feature of the Policy is referred to as • the Accident occurs while the Policy is in force;
the Premium Refund Benefit. and
Who is the benefit paid to? • death occurred immediately or within 90 days
after the Accident.
You can tell us who you want the death benefit
paid to by nominating them as your beneficiary. You
can nominate up to two beneficiaries by completing
the “Nomination of Beneficiary” section at the
time of application. You may change a Nominated
Beneficiary or revoke a previous nomination at any
time prior to a claim event occurring.
4 5
Premiums
Loyalty Discount Benefit
ABOUt YOUR PREMiUMs
To reward you for your loyalty, we will give you
a discount on your Funeral Insurance at MBF The cost of cover depends on your age and your
premium, once you have held your Policy for three chosen level of Sum Insured, which must be in
years or more. The discount applies for the life of multiples of $5,000.
the Policy, increasing each year up to a maximum
of 10% after 10 years. Enjoy a level premium rate for the first 3 years
Usually the cost of your cover increases each
Policy Held For Discount Applied
year as you get older. However, to help you
manage costs, your premium rate is fixed for
3 years 3%
the first 3 years from the Policy Start Date.
5 years 5%
Your premium rate will then increase on the
10 years 10% 3rd Policy Anniversary and will increase each
year in line with your age.
The following table shows the monthly premium for
Private Health Insurance Premium Waiver
various Sums Insured.
If the Life Insured is diagnosed as Terminally Ill
and is a current MBF Health Insurance Member, we All existing MBF Health Insurance Members
will reimburse up to 6 months of your MBF health receive a 10% discount on Funeral Insurance
insurance premiums, subject to a maximum of at MBF premiums.
$2,000 in total.
Monthly Premiums for MBF Health Insurance Members
Reward Cover Benefit
Sum Insured
In the event of death or Terminal Illness, the Sum
Insured paid will be increased by 10% if the Life Age at $5,000 $10,000 $15,000 $30,000 $50,000
Entry
Insured is a current MBF Health Insurance Member
18-39 N/A $13.84 $20.77 $41.53 $69.22
at the time of claim. 40 N/A $13.95 $20.93 $41.86 $69.77
41 N/A $14.18 $21.27 $42.54 $70.90
42 N/A $14.53 $21.79 $43.58 $72.63
43 N/A $15.00 $22.50 $45.00 $75.00
44 N/A $15.53 $23.30 $46.60 $77.67
45 N/A $16.13 $24.20 $48.40 $80.67
46 N/A $16.80 $25.21 $50.41 $84.02
47 N/A $17.46 $26.19 $52.38 $87.30
48 N/A $18.10 $27.15 $54.29 $90.49
49 N/A $18.77 $28.15 $56.30 $93.84
50 N/A $19.58 $29.37 $58.73 $97.89
51 N/A $20.59 $30.89 $61.78 $102.97
52 N/A $21.78 $32.67 $65.35 $108.91
53 N/A $23.11 $34.66 $69.32 $115.54
54 N/A $24.52 $36.79 $73.57 $122.62
55 $13.02 $26.04 $39.06 $78.12 $130.20
56 $13.83 $27.66 $41.49 $82.99 $138.31
6 7
Sum Insured Convenient payment options
Age at $5,000 $10,000 $15,000 $30,000 $50,000 Premiums are payable in advance, either monthly
Entry or annually. If you pay annually, you pay 12 times
57 $14.70 $29.40 $44.10 $88.19 $146.99
58 $15.63 $31.25 $46.88 $93.76 $156.27
the monthly premium.
59 $16.62 $33.24 $49.86 $99.72 $166.20
60 $17.68 $35.36 $53.05 $106.09 $176.82 For your convenience we have a number of easy
61 $18.82 $37.65 $56.47 $112.94 $188.23 payment options for you to choose from, which
62 $20.05 $40.10 $60.14 $120.29 $200.48 helps take the worry out of remembering to pay
63 $21.36 $42.73 $64.09 $128.18 $213.64
your premiums on time.
64 $22.77 $45.55 $68.32 $136.64 $227.73
65 $24.28 $48.56 $72.84 $145.69 $242.81
66 $25.90 $51.79 $77.69 $155.37 $258.95 Monthly Yearly
67 $27.62 $55.25 $82.87 $165.74 $276.24
68 $29.47 $58.95 $88.42 $176.85 $294.74 Direct Debit from your
69 $31.46 $62.91 $94.37 $188.73 $314.56
nominated bank account
70 $33.58 $67.15 $100.73 $201.46 $335.76 Credit Card
71 $35.92 $71.83 $107.75 $215.49 $359.15 (Visa and Mastercard)
72 $38.49 $76.99 $115.48 $230.96 $384.93
73 $41.33 $82.66 $124.00 $247.99 $413.32 Cheque
74 $44.39 $88.78 $133.17 $266.33 $443.89
75 $47.68 $95.36 $143.04 $286.08 $476.79
Aged 90 premium waiver
Commencing from the Policy Anniversary after
the Life Insured turns age 90, premiums for your
Funeral Insurance at MBF Policy will be waived.
Changing your cover
Should your needs change, you can select another
Sum Insured amount from those available and we
will adjust your premium accordingly. Sum Insured
amounts can be increased or decreased only in
multiples of $5,000.
Need help?
If you would like a quote for a Sum Insured
10% discOUNt
not shown above, please call us on 132 623.
FOR MBF HEALtH iNsURANcE MEMBERs
8
Easy Steps Additional Information
EAsY stEPs tO AdditiONAL iNFORMAtiON
APPLYiNg FOR FUNERAL ABOUt FUNERAL
iNsURANcE At MBF iNsURANcE At MBF
If you are a Permanent Australian Resident aged When does cover start?
18 – 75 (inclusive) just follow these easy steps to Once your application has been approved, we will
apply for Funeral Insurance at MBF. confirm for you in writing. We will also issue you
with a Policy Document and Policy Certificate.
1. Read this PDS carefully – it contains important
information about the product, including details The Policy Certificate sets out the details of your
of benefits, costs and exclusions that may apply. cover, including the Life Insured, the Sum Insured
and the Policy Start Date.
2. Choose the amount of cover you want. Cover is
available from $5,000 to $50,000, in multiples of This is an important document and should be kept
$5,000. in a safe place.
3. Decide how you want to pay for your cover.
When does the cover cease?
For your convenience, your monthly or annual
premiums can be automatically deducted from Funeral Insurance at MBF is a guaranteed
your bank account or credit card. If you prefer, renewable Policy, which means that provided you
you can also pay annually by cheque. continue to pay your premiums when due, we
guarantee to continue to provide cover for the Life
4. Complete the application form attached. Insured until the first of the following occurs:
For more information call 132 623, visit
mbflife.com.au or pop by your MBF centre. • the Life Insured dies;
• the Life Insured becomes Terminally Ill;
• we cancel your Policy following your written
request;
• we cancel your Policy because premiums are
unpaid, as and when due; or
• we cancel your Policy in accordance with our
rights in relation to your duty of disclosure.
REAL PROtEctiON
FOR tHE
FUtURE
11
When all cover ceases, the Policy ceases. The • being driven by a person who was under
premiums you pay provide for the cost of your the influence of a drug (other than a drug
cover. The Policy does not provide for a residual prescribed by a Doctor and taken as directed);
cash or surrender value. This means that if you or
cancel your Policy after the cooling off period
or if we cancel your Policy in accordance with • being driven by a person who was under the
our rights, you will not receive a residual cash influence of alcohol in excess of the legal blood
or surrender value. If however you have paid an alcohol limit.
annual premium, we will pay a pro-rata premium
refund of any unused premium on your Policy. Can premium rates change?
Premium rates are not guaranteed and we reserve
When benefits will not be paid the right to review our rates at any time. Any
No benefit will be paid within 24 months of the changes to our standard rates will apply to all
Policy Start Date or the date of reinstatement of the Funeral Insurance at MBF policies in a defined
Policy, whichever is the later, if the cause of death group, we will not single you out for a premium
was not an Accident. increase. If we need to change our rates, you will
be given 30 days notice in writing.
If the Sum Insured has been increased, the amount
of the increase will not be paid if within 24 months
after the date of the increase the Life Insured dies
and the cause of death was not an Accident.
No Terminal Illness benefit will be paid if the Life
Insured is diagnosed as Terminally Ill within 24
months of the Policy Start Date or reinstatement of
the Policy, whichever is the later.
The additional Motor Vehicle Accident benefit will
not be paid if the Motor Vehicle in which the Life
Insured was travelling was:
• in an unsafe condition, as determined by our
expert;
• being used in a race, trial, contest or for
unlawful purposes;
• being driven unlawfully;
12 13
Insurance Policies
ABOUt iNsURANcE What is the cooling off period?
POLiciEs issUEd BY
If for any reason you decide that your Policy
does not meet your needs, you can cancel it by
cLEARViEW LiFE notifying us in writing within 14 days, starting on
the earlier of:
AssURANcE LiMitEd • the date you receive your Policy; or
How do I make a claim? • 5 business days after your Policy Start Date.
The procedure for making a claim is outlined in This is known as the cooling off period. Provided
the Policy Document. In particular, we need to be you cancel your Policy within the cooling off period,
notified of a claim as soon as possible. We will we will refund any premiums you have paid.
need all the evidence we reasonably regard as
necessary to establish entitlement to a benefit. You will not be able to cancel your Policy under the
cooling off period provision if you have exercised
We are committed to paying claims as quickly as any rights under it, for example, if you have made
possible, and have a service standard of 48 hours, a claim under your Policy.
once all claims requirements have been received in
our office. What are the tax implications?
What will happen if I stop paying my premiums? Generally premiums are not tax deductible and
benefits are free of personal tax. This is a general
To ensure your Policy remains in force you must statement based on the continuance of taxation
pay your premium, as and when due. If you don’t laws and their interpretation that were current
pay your premium within 30 days of the due date, at the date this document was prepared. You
we will write to you explaining how we can cancel should seek advice from a suitably qualified
your Policy. If we cancel your Policy all cover will taxation professional, in relation to your particular
cease and you will not be able to make a claim for circumstances.
an event which occurs after the date cover ceases.
Is my cover guaranteed renewable?
You may apply to ClearView Life Assurance Limited
to reinstate your Policy after it is cancelled, subject If you pay your premiums and comply with Policy
to our approval and payment of outstanding conditions, your cover is guaranteed renewable
premiums. up until the Policy Expiry. This means that we
cannot cancel your cover or increase the premium
Are there any other charges? because of any change to your state of health,
occupation or pastimes.
The insurance premium is the only amount payable.
There are no additional charges. The premium
includes allowances for current government
charges and taxes.
We may pass on to you any applicable new or
increased government taxes or charges.
14 15
Privacy
What are the complaint handling procedures for
ClearView Life Assurance Limited? PRiVAcY ANd YOUR
At ClearView Life Assurance Limited, customer PERsONAL iNFORMAtiON
satisfaction is very important to us. Should you be
dissatisfied with your Funeral Insurance at MBF or We are committed to ensuring the confidentiality
with ClearView Life Assurance Limited, please let us and security of your personal information including
know by telephoning 132 623. sensitive information. All personal information will
be handled in accordance with the Privacy Act.
We do our best to resolve all complaints within
7 days of notification. If your complaint is not Collection, Use and Disclosure of your
resolved to your satisfaction, or you are not Personal Information
satisfied with the progress after 7 days, please
contact: We need to collect, use and disclose your personal
information including sensitive information or that
Complaints Manager of the Life Insured (if not you) in order to consider
ClearView Life Assurance Limited your application and to provide the cover you have
Reply Paid 4232 chosen, administer the Policy and assess any claim.
Sydney NSW 2001 You or the Life Insured can choose not to provide
us with some or all of your personal information
If you are not satisfied with how we respond to including sensitive information, but this may affect
your enquiry or complaint or we have not dealt our ability to provide the cover.
with your complaint within 45 days (or within any
extended period you approve), you may contact the By providing your personal information including
Financial Ombudsman Service on 1300 780 808, sensitive information or that of the Life Insured you
or by writing to the address below. This service is and the Life Insured acknowledge and declare that,
provided to you free of charge. and consent to the following:
The Manager • we can collect and use your personal
Financial Ombudsman Service information including sensitive information
GPO Box 3 for the following purposes: to assess any
Melbourne VIC 3001 application; underwrite; price and issue any
Policy; calculate or offer benefits and discounts;
administer the Policy; to investigate, assess and
pay any claim;
• for these purposes we can collect your personal
information including sensitive information from,
and disclose it on a confidential basis to: our
related entities; outsource providers; government
departments and agencies; investigators;
lawyers; advisers; medical and health service
providers; reinsurers; other insurers; anyone
acting on our behalf; and the agent of any of
these;
16 17
• where you provide personal information Our Information Handling Policy
including sensitive information to us about
Further information on how we handle your
another person, you are authorised to provide
personal information is explained in our Information
their information to us, and that you will inform
Handling Policy including:
that person who we are, how we use and
disclose their information, and that they can • how to contact us regarding Privacy;
gain access to that information (unless doing so
would pose a serious threat to the life or health • how to inform us to change your marketing
of any individual). consent; and
Marketing • how to access your personal information.
We are committed to providing you with access to a If you have any questions, comments or concerns
range of leading products and services. regarding privacy matters or any other matter, or if
you would like a copy of our Information Handling
In order to do this we will use your personal Policy, please call us on 1800 213 839.
information to offer you other products and
services. We may disclose your personal information
on a confidential basis to our related entities within
ClearView so that they can also offer you products
and services.
By providing your personal information to us you
acknowledge that, and consent to:
• us collecting and using your personal
information to contact you for market research
and to provide you information and offers
about products and services offered by us,
our related entities, within ClearView and other
organisations whose products and services we
promote;
• us disclosing your personal information on a
confidential basis for these marketing purposes
to our related entities and to any agent of them;
and
• you will inform us if you do not want your
personal information to be used, or disclosed
for these marketing purposes, by telephoning
1800 213 839.
18 19
Disclosure Definitions
YOUR dUtY OF dEFiNitiONs
discLOsURE ‘Accident/Accidental’ means an unintended and
unexpected event, which occurs while this Policy is
Under the Insurance Contracts Act 1984, the person in force and where the Life Insured suffers physical
who is the Life Insured, has a duty, before the injuries caused solely and directly by visible, violent
contract of life insurance is entered into with us, to and external means and where the injury is not
disclose every matter that the Life Insured knows, self inflicted.
or could reasonably be expected to know, that is
relevant to our decision whether to accept the risk For the avoidance of doubt, Accident excludes:
of the insurance and, if so, on what terms.
• suicide and/or events where the injury and/or
The Life Insured has the same duty to disclose death was unintended and unexpected but was
those matters to us before the insurance is the result of an intentional act;
extended, varied or reinstated. This duty, however,
does not require disclosure of a matter: • death or injury due to natural causes;
• that diminishes the risk to be undertaken by us; • vascular Accidents;
• that is of common knowledge; • allergic reactions; or
• that we know or, in the ordinary course of our • any event relating directly or indirectly to any
business, ought to know; or surgical procedure.
• if we have waived in writing our requirement to ‘Accidental Death’ means death resulting from an
comply with this duty. Accident either immediately or within 90 days after
the Accident.
Non-disclosure
‘Accidental Death Only Period’ means the period
If the Life Insured fails to comply with their duty where the Sum Insured will only be paid if the
of disclosure and we would not have entered Life Insured dies as a result of an Accident. This
into the contract on any terms if the failure had period is 24 months commencing on the Policy
not occurred, we may void the contract within 3 Start Date, date of reinstatement or the date of a
years of entering into it. If your non-disclosure is Sum Insured increase (but only in respect of the
fraudulent, we may void the contract at any time. increase amount). No Terminal Illness benefit will be
If we are entitled to void a contract of insurance paid if the Life Insured is diagnosed as Terminally
we may, within 3 years of entering into it, elect not Ill during the Accidental Death Only Period.
to void it but reduce the amount of the insured
benefit in accordance with a formula that takes ‘Inflation’ means the last weighted average of
into account the premium that would have been 8 capital cities combined Consumer Price Index
payable if all relevant matters had been disclosed published by the Australian Bureau of Statistics as
to us. at the time indexation is being calculated. If this
index is no longer being published, we will use
another index which we consider is similar to it.
20 21
‘Life Insured’ means the Life Insured stated in the ‘Permanent Australian Resident’, means the holder
Policy Certificate. of a current valid Australian passport or a person
who has been granted a permanent resident visa.
‘MBF Health Insurance Member’ means a customer
who holds current private health insurance cover ‘Policy’ means the Funeral Insurance at MBF Policy,
issued by a Bupa Australia company. which is a contract of insurance between you
and ClearView Life Assurance Limited, and which
‘Medical Practitioner’ means a person acceptable comprises the Funeral Insurance at MBF Policy
to us who is qualified, registered and practising in Document, the Policy Certificate (as applies from
Australia as a Medical Practitioner, other than: time to time) and any other documents we issue to
you at time of acceptance of cover.
- you;
‘Policy Anniversary’ means an anniversary of the
- the Life Insured;
Policy Start Date.
- a member of the Life Insured’s or your
‘Policy Certificate’ is the Policy Certificate issued
immediate family;
upon confirmation of issue of cover or any
- your business associate; or replacement Policy Certificate we issue.
- the Life Insured’s business associate. ‘Policy Owner’ means the Policy Owner stated in
the Policy Certificate.
We may also accept a person with similar
qualifications who is registered and practising ‘Policy Start Date’ means the date the Policy starts,
as a Medical Practitioner in another country. as stated in the Policy Certificate.
‘Motor Vehicle’ means a registered vehicle ‘Premium Refund Benefit’ means we will refund all
(including a motor bike), which is: premiums paid on the Policy if the Life Insured dies
from any cause other than an Accident during the
• able to be driven on public roads and Accidental Death Only Period and no other claim is
motorways; paid.
• used purely for business and/or personal use; ‘Sum Insured’ means the insured amount stated in
and the Policy Certificate.
• in use for the purpose for which it is registered. ‘Terminally Ill/Terminal Illness’ means an illness
that, in the opinion of an appropriate specialist
‘Motor Vehicle Accident’ means an Accident Medical Practitioner, will lead to the death of the
involving a Motor Vehicle that occurs while the Life Insured within 12 months.
Policy is in force, where the Life Insured was the
driver or passenger of the Motor Vehicle.
‘Nominated Beneficiary’ means a Nominated
Beneficiary selected by you whilst the Policy is in
force and prior to any claim and confirmed by us
in writing.
22 23
CALL 132 623
VISIT mbflife.com.au
POP BY your MBF centre
ClearView Life Assurance Limited
Level 4, 50 Bridge Street
Sydney NSW 2000
Issued by: ClearView Life Assurance Limited
ABN 12 000 021 581
AFS License No. 227682
CVWMBFL 0036
10% PREMIUM DISCOUNT FOR
MBF HEALTH INSURANCE MEMBERS
This application relates to Funeral Insurance at MBF, Product Disclosure Statement (PDS) dated 1 January 2011.
Please do not complete this application if you have not read the PDS.
Application form – Funeral Insurance at MBF
To be eligible to apply, you must be a Permanent Australian Resident aged between 18 and 75 (inclusive).
If you wish to apply for cover for a second person, you will need a separate application form.
Send your completed application form (no stamp required) to: Clearview Life Assurance Limited. Reply Paid 4232, Sydney NSW 2001.
Select amount of cover (tick one box only, or specify amount)
$5,000 $10,000 $15,000 $20,000 $50,000 Other Amount
(min*) (max.) (must be a multiple of $5,000)
$
Note: $10,000 is the minimum amount of Funeral Insurance at MBF cover for an applicant up to and including age 54.
Life Insured details (please print)
Title Given name(s) Initial Mobile phone number Date of birth Sex (M/F)
Surname Email address
Address
1. Are you a permanent resident of Australia?
State Postcode Yes No
Home phone number 2. Are you an MBF Health Insurance Member?
Yes No
Nomination of beneficiaries
Full name of Beneficiary Address Date of birth Relationship Portion of total
to the Life benefit %*
Insured
State Postcode
State Postcode
*Each portion must be a whole percentage and the total must add up to 100%.
Declarations
My decision to apply for this insurance is based on the material received and my understanding of the information, including the PDS.
I have read and understand the ‘Your Duty of Disclosure’ and ‘Non-Disclosure’ statements in the PDS and confirm that I am a permanent Australian resident aged
between 18 and 75 (inclusive).
I have read and consent to the collection, use and disclosure of my personal information including sensitive information, as set out in the ‘Privacy and Your Personal
Information’ section of the PDS, including the Marketing Purposes section.
I understand that the insurance applied for does not begin until Clearview Life Assurance Limited accepts my application.
Applicant’s signature
Payment Authority
This authority must be completed if you wish to pay by automatic deductions from either a credit card or a bank account.
Select preferred payment method (tick one box only)
I wish to pay my premiums:
Monthly (by automatic deductions from my bank account or credit card) – please complete payment authority
Annually (by automatic deductions from my bank account or credit card) – please complete payment authority
Annually (by manual payments) – please make your cheque for 12 times the monthly premium, payable to Clearview Life Assurance Limited
Option A – Credit card Cardholder’s name (as shown on card) Expiry date
I authorise Clearview Life Assurance Limited to deduct payments from my:
Cardholder’s signature
MasterCard Visa
Cardholder’s signature
Credit card number
Option B – Bank account
I authorise the payment of premiums for the Policy by automatic debit from my account in accordance with the Direct Debit Request below:
Request and authority to debit
ClearView Life User ID 022829 may debit and/or charge any amount through the Bulk Electronic Clearing System, from the account nominated
on this form. Each debit or charge must be effected according to the Service Agreement.
Direct Debit request – authority to debit account:
Title Given name(s) Name of account holder
Surname BSB number Account number
–
Address
Before signing this section, please read the Direct Debit Service Agreement in
State Postcode
the PDS. If your Authorisation is accepted, the full Service Agreement will be
sent to you with your Policy Document. Your signature on this form confirms
Details of financial institution you have authorised ClearView Life Assurance Limited to deduct premiums from
your account according to the Service Agreement and that you have checked
Name of financial institution
the account details and confirm they are correct. If a joint account, please have
all account holders sign. If you are signing for and on behalf of another person,
please state the capacity in which you sign, in the signature box below.
Address of financial institution
Cardholder/s signature
State Postcode
Thank you for your application
OFFICE USE ONLY
Send your completed application form (no stamp required) to:
Consultant Name
Clearview Life Assurance Limited
Reply Paid 4232
Sydney NSW 2001
Consultant ID (BOSS) Retail Centre Name
Issuer: Clearview Life Assurance Limited
ABN 12 000 021 581
AFS Licence No. 227682
CVWMBFL 0036
