asgard employee super insurance application...1 of 8 asgard employee super insurance application...

Asgard Employee Super Insurance Application1 of 8

Asgard Employee SuperInsurance Application

Before you sign this application, be aware that the Trustee or the financial adviser for your account is obliged to have provided you with a brochure containing the summary of important information in relation to this product. This information will help you to understand the product and to decide whether it is appropriate to your needs.

Please read carefully the ‘Privacy statement’ in the Asgard Employee Super Account - Additional Information Booklet Part 1 – General. It sets out important information you should know about the Insurer and the Trustee’s handling of personal information about you.

A copy can be obtained from asgard.com.au. Complete this form in BLOCK LETTERS using Black ink and, post it to Asgard, PO Box 7490, Cloisters Square WA 6850.

Questions? Please call us on 1800 998 185 or email [email protected].

BT Funds Management Limited ABN 63 002 916 458 AFSL 233724 (‘the Trustee’ of Asgard Employee Super Account) holds the Master Policies of insurance issued by Westpac Life Insurance Services Limited ABN 31 003 140 157 AFSL 233728 (‘the Insurer’).

Asgard Capital Management Ltd ABN 92 009 279 592 AFSL 240695 (‘the Administrator’) provides administration services in relation to this cover.

1. Employer details

Employer name

111111111111111111111111111111111111112. Account details

Account number Date of birth

1111111 – 11 – 1111|11|1111Title Surname

1111111111111111111111111111111111111Given names

11111111111111111111111111111111111111Residential address (PO Box is not acceptable)

1111111111111111111111111111111111111111111111111111111111111111 State 111 Postcode 1111Postal address (if different from residential address)

1111111111111111111111111111111111111111111111111111111111111111 State 111 Postcode 1111Date of birth Gender

11|11|1111 Male Female

Email

11111111111111111111111111111111111111*In future, Asgard may elect to email correspondence to you

Phone (Home) Phone (Mobile)

1111111111 1111111111

http://asgard.com.au

mailto:client.support%40asgard.com.au?subject=


Duty of Disclosure

Your Duty of Disclosure

Before you become covered by the Insurer, or extend, vary or reinstate your insurance cover, you need to disclose to the Insurer anything that you know, or could reasonably be expected to know, may affect the Insurer’s decision to insure you and on what terms.

However, you do not need to tell the Insurer anything that:

> reduces the Insurer’s risk, or

> is common knowledge, or

> the Insurer knows or should know as an insurer, or

> the Insurer waives your duty to tell it about.

If you do not tell the Insurer something

The Insurer has a number of rights in the event of non-disclosure. In exercising these rights, the Insurer may consider whether different types of cover can constitute separate contracts of life insurance. If they do, the Insurer may apply the following rights separately to each type of cover. The rights are as follows:

> If you do not tell the Insurer anything you are required to, and the Insurer would not have provided the insurance if you had told them, the Insurer may avoid the contract within three years of entering into it.

> If the Insurer chooses not to avoid the contract, the Insurer may, at any time, reduce the amount of insurance provided. This would be worked out using a formula that takes into account the premium that would have been payable if you had told the Insurer everything you should have. However, if the contract provides cover on death, the Insurer may only exercise this right within three years of entering into the contract.

> If the Insurer chooses not to avoid the contract or reduce the amount of insurance provided, the Insurer may, at any time vary the contract in a way that places the Insurer in the same position they would have been in if you had told the Insurer everything you should have. However, this right does not apply if the contract provides cover on death.

> If the failure to tell the Insurer is fraudulent, the Insurer may refuse to pay a claim and treat the contract as if it never existed.

Use this form if you would like to apply for insurance cover, or increase your current insurance cover arrangements under your superannuation plan. The level and types of cover which currently apply to you are specified on your Welcome Pack or latest Investor Report. Depending upon how you answer these questions, you may be required to complete additional questionnaires. The additional questionnaires are located online at Investor Online. The Insurer reserves the right to refuse cover.

Privacy Consent

I have read the Privacy section of the Additional Information Booklet and I agree to the various uses and disclosures of my personal information (including my health information) set out in that section.

I hereby consent to the Trustee collecting, using and disclosing my personal health information (including disclosure to the Trustee’s Insurer and to the Insurer’s reinsurers, contractors or third party service providers) for the purpose of assessing your eligibility for cover and assessing claims you make, and for directly related purposes.


3. Insurance Required

Additional information and medical testing may be required. You will be contacted with specific requirements if you are impacted by this.

Type of insurance cover Amount

Life Protection Only $

Life and Total & Permanent Disablement (TPD)1 Protection

Life Protection $

TPD $

Salary Continuance Insurance (SCI) Cover (maximum of 75% of Income2 plus up to 15% super contributions benefit if selected)

Please select both the waiting period and benefit period required:

SCI

%

Waiting period (days)

30

60

90

Benefit period (maximum)

2 years

To age 65

1 The amount of TPD Protection should be equal to or less than Life Protection.2 Please refer to the Additional Information Booklet Part 3 – Insurance for the definition of ‘Income’.Note: Casuals and contractors may apply only for a 2 year benefit period

4. Adviser Information

Adviser name

11111111111111111111111111111111111111Company name

11111111111111111111111111111111111111Adviser number

11111111111111111111111111111111111111Postal address (if different from above)

1111111111111111111111111111111111111111111111111111111111111111 State 111 Postcode 1111Email

11111111111111111111111111111111111111Adviser phone (business) Adviser phone (mobile)

1111111111 1111111111Do you want your adviser to be able to track the progress of this application?

3 No

3 Yes

Note: If you answer YES to this question, health information relating to your application for insurance may be provided to your adviser.


Before you begin:

This personal statement provides the Insurer with information needed to determine whether to insure you and on what terms. It takes most people about 15 minutes to complete this personal statement.

Before completing this form, please read:

The ‘Privacy Information’ section in the Additional Information Booklet Part 1 – General for information on how we collect, use and store your information the information about your Duty of Disclosure.

Having the following information ready will help you complete this personal statement:

> You current annual income;

> Details of other life, disability or income insurance you hold or are applying for;

> Your height and weight;

> Details of your health history including any medications or other treatment and investigations you have had in the last 3 years as well as details of any ongoing, recurrent or significant health related conditions.

You may be prompted to answer additional questions to provide further detail following a ‘yes’ answer. If you answer ‘yes’ to a question about your health we may ask you to also complete a supplementary questionnaire. Completing the supplementary questionnaire(s) will assist us in the assessment of your application. The supplementary questionnaires are available online at Investor Online.

If you require assistance, please contact our Customer Relations team on 1800 998 185.

5. Residency

Are you an Australian or New Zealand citizen, or do you hold a visa that allows you to permanently reside in Australia or to live and work in Australia? Yes No

6. Employment details

Are you currently gainfully employed?

3 No ➤ If you are currently not working, what is your status? 3 Unemployed 3 Retired 3 Not working due to ill health

Last date of employment 11|11|1111

3 Yes ➤ Employed: 3 Full time 3 Permanent part-time 3 Casual 3 Contractor

Term of contract (if employed on a fixed term contract) 11 years and 11 months

3 Self Employed (eg. sole trader, business partner or employee of own business)

7. Occupation details

Only complete the below section if you are employed or self-employed, otherwise proceed to section 8. Other insurance.

What is your occupation and industry?

11111111111111111111111111111111111111Do you work at heights over 10m, underground or offshore more than 40% of your working hours, or handle explosives? Yes No

If Yes ➤ please provide further details below of your work duties and the percentage of time performing each duty:

How many hours per week do you work in your principal occupation? 11What is your current annual income1? $ 111,111.111 Please refer to Additional Information Booklet Part 3 – Insurance for the definition of ‘Income’


8. Other insurance

Apart from the cover you are applying for as part of this application, do you have or are you applying for any death, TPD and/or salary continuance or income protection cover with Westpac, Asgard or any other company? This includes insurance benefits under superannuation, business or credit insurance, or provided by your employer. Yes No

If Yes ➤ please provide further details below of your work duties and the percentage of time performing each duty:

Type of insurance cover

Insurer Reason for cover

Was this cover underwritten? Personal When

commencedInsured amount

Are you retaining the cover

Yes No Yes No

Yes No Yes No

Yes No Yes No

Yes No Yes No

9. Personal details

Do you participate in, or intend to participate in, any of the following sports or pastimes? Yes No

If Yes ➤ please provide further details below:

> Underwater diving

> Motor sports (including trail bike riding)

> Football

> Climbing, abseiling, mountaineering

> Boxing, martial arts, wrestling or any combat sports

> Aerial activities such as flying (other than as a passenger on a regular airline) or parachuting

> Competitive water, ice or snow sports (other than swimming)

> Competitive horse riding or rodeo > Any other sport or pastime involving speeds over

100 km/hour or heights over 10m

If Yes ➤ please provide further details below:

Details of Sport/Pastime Frequency (per month) Amateur competition, Professional, or Recreational only

Have you smoked tobacco or any other substance within the past 12 months, or used a product containing nicotine within the last 3 months? Yes NoIf Yes ➤ please advise type and average amount per day:

Type (e.g.cigarette, pipe, nicotine patches) Amount per day

What is your height and weight?

Height 111 cm OR 1 ft 11 in

Weight 111 kg OR 11 st 11 lbs


10. Health Information

1. Do you have, or have you ever had any of the conditions listed below?

High blood pressure? Yes No

If Yes ➤ please also provide the following details:

Have you had blood reading that was more than 145/90 in the last 12 months? Yes No

Do you have any complications related to high blood pressure such as heart disease, a heart disorder, abnormal kidney function, eye problem? Yes No

If you answered Yes to any of the above questions, please, complete the High Blood Pressure Questionnaire

High cholesterol? Yes No


Have you had a cholesterol result that was more than 6.5 in the last 12 months? Yes No

Do you have any complication related to high cholesterol such as heart disease, stroke or familial hypercholesterolaemia? Yes No


Back or neck pain, strain, disease or disorder? Yes No


Has a back or neck disorder been diagnosed as anything other than muscular strain or pain? (e.g. arthritis, a disk issue, nerve impingement) Yes No

Have you ever had, or has it been recommended that you have, surgery for a back or neck disorder? Yes No

In the last 2 years have you experienced symptoms, received treatment (eg. Physiotherapy, chiropractic, osteopathy or prescription medications), or attended a health service provider for a back or neck disorder? Yes No

Have you had more than 5 consecutive days off work or on limited duties due to a back or neck disorder Yes No


Joint or muscle disorder, such as pain, strain, sprain, tear, dislocation, fracture, gout, tendonitis or arthritis? Yes No


Have you ever had any joint or muscle disorder(s) that was anything other than a strain, sprain or fracture? Yes No

Have you ever had a joint or muscle disorder(s) that required surgical repair or reconstruction? Yes No

Have you had any symptoms from, or require any treatment for, any joint or muscle disorders(s) in the last two years? Yes No

Have you had more than 5 consecutive days off work or on limited duties due to any joint of muscle disorder? Yes No


Diabetes? (excluding gestational diabetes where blood glucose levels have returned to normal) Yes No

If Yes ➤ please complete the Diabetes Questionnaire

Anxiety, depression, stress disorder or any other mental health disease or disorder? Yes No

If Yes ➤ complete the Mental Health Questionnaire

2. Have you ever had any medical advice, counselling or treatment due to alcohol or drug use? Yes No

If Yes ➤ The Insurer will call you directly on the phone number provided. If they cannot reach you a confidential questionnaire will be sent to you.

3. Do you have, or have you ever had, any of the conditions listed below? Yes No

Heart attack, angina, irregular heartbeat, or any heart or blood vessel disease or disorder (other than varicose veins? Yes No

Melanoma or Cancer of any kind Yes No

Epilepsy, head injury, stroke, paralysis or any disease or disorder of the brain, spinal cord or nerves Yes No


10. Health Information (continued)

4. In the last 3 years, have you had a medical investigation, test (excluding genetic testing) or consultation that resulted in:

Referral to a medical specialist Yes No

A surgical procedure Yes No

Diagnosis of a medical condition or disorder Yes No

Advice to undergo further medical investigations, tests or consultations Yes No

5. Are you currently off work due to injury or illness, apart from for the common cold or flu? Yes No

6. Have you in the last 5 years been off work for more than 15 consecutive days due to anything other than flu or cold, chicken pox, measles, dental surgery, tonsillitis or appendicitis? Yes No

7. Are you contemplating, or have you been told to seek any medical advice, tests, investigations or treatments not already disclosed? (other than genetic testing, dental, childbirth or fertility related, routine or work related health check up) Yes No

NB: Please only answer question 8 if the combined total of insurance cover being applied for and any existing cover that you have with all companies (including individual and group insurance) exceeds:

> $500,000 Death cover

> $500,000 Total and Permanent Disability (TPD)

> $4,000 per month Income Protection/Salary Continuance Insurance (SCI)/Group Salary Continuance (GSC)/Business Overheads/ Key Person Income

8. Genetic Testing a. Have you ever had a genetic test or have you consented to having a genetic test? Yes No

b. If Yes ➤ have you received or do you expect to receive a result from your genetic test? Yes No

If Yes ➤ please provide full details of the genetic test including the result (if available) and any further treatment, investigation, test, consultation or operation you have had or intend to have.

If No ➤ please advise the reason you have not received and do not expect to receive a result from your genetic test.

If you answered ‘Yes’ to any of Questions 2–7 please also complete the table below:

Question number

Condition/ injury/ symptom

Treatment, tests, investigations, time off work

Date first occurred

Date of last symptom or treatment

Degree of recovery

Name & address of health service provider attended

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

/ / / /

11. Doctor details

If you answered ‘Yes’ to any of Questions 1–8, please provide details of your usual doctor(s) or medical centre(s).

Name of your usual doctor(s) Doctor’s address


12. Family history

1. To the best of your knowledge, have any of your blood related parents, brothers or sisters (living or deceased) had any of the following conditions before the age of 60?

Alzheimer’s disease or dementia Yes No Multiple sclerosis Yes No

Cardiomyopathy Yes No Muscular dystrophy Yes No

Familial polyposis of bowel (FAP) Yes No Parkinson’s disease Yes No

Huntington’s disease Yes No Polycystic kidney disease Yes No

Motor neurone disease Yes No Any other hereditary disease or disorder Yes No

2. To the best of your knowledge, have two or more of your blood related parents, brothers or sisters (living or deceased) had any of the following conditions before the age of 60?

Diabetes Yes No Stroke Yes NoHeart attack, coronary artery bypass or had a stent Yes No

Cancer Yes No

If you answered ‘Yes’ to question 1 or 2, please provide details for each family member in the table below (please also include site of cancer):

Disease or disorder No. of relatives affected Age diagnosed

13. Declaration

I declare and agree that:

> I have read and understood this completed form and declare that the statements made and the information completed therein is true and correct as at the date I signed this form;

> I have read the Privacy section of the Additional Information Booklet in the Product Disclosure Statement and I agree to the various uses and disclosures of my personal information set out in that section;

> I have read and understood the section titled ‘Duty of Disclosure’ in this form. I declare that I have complied with the duty of disclosure;

> this form shall form part of my insurance and the basis of cover issued or reinstated;

> I understand that failure to comply with the duty of disclosure could result in variation, avoidance or cancellation of my insurance, or any claim not being paid in accordance with my expectations;

> I understand that the duty of disclosure extends beyond my completion of this form up until the Insurer accepts the reinstatement of insurance cover to which this form relates;

> the email address provided in this application may be used to electronically communicate with me, including important information in relation to my application and my insurance;

> if no further information is requested by the Insurer then any insurance cover I currently have, and the premium payable, will be adjusted from the date that Asgard receives this fully completed.

> a photocopy of this declaration shall be as valid as the original.

Signature of Life Insured

Date

11|11|1111Signatory name

11111111111111111111111111111111111111

Customer Relations: 1800 998 185Correspondence to: Asgard, PO Box 7490 Cloisters Square WA 6850Trustee: BT Funds Management Limited ABN 63 002 916 458Insurer: Westpac Life Insurance Services Limited ABN 31 003 149 157

AESA60616_1119vx

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