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Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 Trustee of AustralianSuper ABN 65 714 394 898
Change your insurance
Before you change your cover you should read the Insurance in your super guide. It contains terms and conditions about insurance, including
costs, your eligibility for cover, how much you can apply for, what you’re covered for, when it starts and stops, active employment, limited
cover and exclusions, and your insurance options. Download a copy for your division at australiansuper.com/InsuranceGuide If you apply
to make any changes to your cover and your application is accepted, it will start automatically even if you haven’t turned 25 and your super
balance hasn’t reached $6,000*. This means that the cost of your cover will start to be deducted monthly from your super account from the
later of the date your application is accepted and the date your cover starts (see the When your cover starts section of the Insurance in your
super guide for details).
If you haven’t turned 25 you’re not eligible for age-based cover, but you can apply for extra (fixed) or fixed Death and/or Total & Permanent
Disablement (TPD) cover or fixed Income Protection. Your ability to claim for benefits will be determined by the Insurer in line with our policy
terms and conditions.
* Age-based cover will start when you turn 25 (if you’re eligible)
Here are the cover designs we oer:
Cover designs
Type of cover available
Death and TPD Income Protection
Age-based cover Both the amount of cover you get and the cost of it changes as you get older.
✔
✔
Age-based cover
+ extra (fixed)
cover
You can add an extra amount of cover on top of your age-based cover. The extra
amount is provided as fixed cover and will stay the same as you get older (unless
you change it) but the cost will change.
✔
n/a
Fixed cover You can apply for a total amount of fixed cover. This means your total amount of cover
stays the same as you get older (unless you change it) but the cost will change.
✔
✔
Your application is subject to consideration by the Insurer. Go to australiansuper.com/ChangingCover to understand how the Insurer
considers your application.
Before you change your cover:
•
Check your latest statement or log into your account to understand what type and how much cover you have.
•
Use our insurance calculator at australiansuper.com/InsuranceCalculator to work out the right level of cover for you, and the cost of it.
•
Read the Duty to take reasonable care statement in section 3.1.
If you want to: Complete section(s)
Cancel all or part of your cover 2. Cancel your cover
Apply for new cover or
increase your cover amount(s)
3.1 Duty to take reasonable care
3.2 Your salary and occupation details
4. Start your age-based cover
5. Death and TPD cover
6. Income Protection
8. Health questions
You may need to complete the Detailed Health Statement. See the checklist in PART TWO of this form.
Decrease your cover amount
or switch basic cover to fixed
cover (same amount(s))
5. Death and TPD cover
6. Income Protection
Apply to change your
individual work rating
3.1 Duty to take reasonable care
3.2 Your salary and occupation details
7. Change your individual work rating
Change your Income Protection:
•
waiting period
•
benefit payment period
3.2 Your salary and occupation details
6.1 Waiting period and benefit payment period
8. Health questions. Please complete section 8 if you’re:
•
applying for a benefit payment period of up to five years or up to age 65, or
•
aged 63 or 64 and reducing your benefit payment period to two years
(which means you’re extending your cover to age 70).
You may need to complete the Detailed Health Statement. See the checklist in PART TWO of this form.
You’ll also need to:
Complete all of the questions in section 1: Your personal details.
Sign and date the Declaration in section 15.
AustralianSuper will only make changes to each type of cover you change on this form.
20742 09/21 page 1 of 12
Use this form to apply for new cover or to start, increase, reduce, change or cancel your cover to suit your
needs. You can also apply to change your individual work rating and Income Protection waiting period
and/or benefit payment period.
1. YOUR PERSONAL DETAILS
Last name Mr Mrs Miss Ms Dr
First name
Date of birth Your member number Gender
D
D
M
M
Y
Y
Y
Y
M
F
Street address
Suburb State Postcode
Postal address (if dierent)
Suburb State Postcode
Telephone (business hours) (after hours) Mobile
To process your application, the Insurer may send you specific health questionnaires to complete. To receive them by email
please provide your address below:
Email
If I provide my email address and/or phone number, I’m consenting to AustralianSuper communicating with me via email, my
online account, mobile app and phone as appropriate. I understand I can change my communication preferences through my
online account or by calling 1300 300 273.
2. CANCEL YOUR COVER
Complete this section to cancel any part of your cover (or all of it).
When you cancel your cover you won’t be insured for that cover from the date your cancellation is accepted. This means for the
type of cover you cancel:
•
Your basic cover won’t start when you become eligible.
•
You (or your beneficiaries) won’t be able to make an insurance claim if something happens after the cancellation.
•
The cost of cover will stop being deducted from your super account (costs are deducted one month in arrears).
•
You might not be able to get cover later. That’s because you’ll need to reapply and provide detailed health information for the
Insurer to consider.
If you’re replacing this cover with another insurance policy, before you cancel you should wait until the other insurer confirms
your cover has started.
You should consider getting financial advice to help work out if cancellation is right for you. Go to australiansuper.com/advice
for more information.
Print (✗) next to each type of cover you wish to cancel.
I want to cancel my age-based cover
Death TPD Income Protection
I want to cancel my extra (fixed) cover
Death TPD
I want to cancel my fixed cover
Death TPD Income Protection
I want to cancel ALL of my cover
Death TPD Income Protection
Go to section 15 if you’re only completing sections 1 and 2.
Please complete in pen using CAPITAL letters and print
✗
to mark boxes where applicable. Read the Privacy Collection
Statement at the end of this form to see how AustralianSuper uses your personal information.
20742 09/21 page 2 of 12
Change your insurance
Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 Trustee of AustralianSuper ABN 65 714 394 898
AustralianSuper insurance is provided by TAL Life Limited (the Insurer), ABN 70 050 109 450, AFSL 237848
A Target Market Determination (TMD) is a document that outlines the target market a product has been designed for.
Find the TMDs at australiansuper.com/tmd
Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 Trustee of AustralianSuper ABN 65 714 394 898
3. APPLY TO START OR CHANGE YOUR COVER
If you want to:
•
start your age-based cover – read section 3.1, then complete section 4
•
apply for cover – read section 3.1, then complete sections 5 and/or 6
•
apply for a dierent cover amount or fix all or part of your cover – read section 3.1, then complete sections 3.2, 5 and/or 6
•
change your Income Protection waiting period or benefit payment period – read section 3.1, then complete section 6.1
•
change your individual work rating – read section 3.1, then complete sections 3.2 and 7
Before you make any changes to your cover, make sure you read the Duty to take reasonable care statement below.
3.1 Duty to take reasonable care
20742 09/21 page 3 of 12
The duty to take reasonable care
When you apply for insurance, you are treated as if you are
applying for cover under an individual consumer insurance
contract. A person who applies for cover under a consumer
insurance contract has a legal duty to take reasonable care not
to make a misrepresentation to the Insurer before the contract
of insurance is entered into.
A misrepresentation is a false answer, an answer that is only
partially true, or an answer which does not fairly reflect the truth.
This duty also applies when extending or making changes to
existing insurance, and reinstating insurance.
If you do not meet your duty
If you do not meet your legal duty, this can have serious
impacts on your insurance. Under the Insurance Contracts Act
1984 (Cth) there are a number of dierent remedies that may
be available to the Insurer. They are intended to put the Insurer
in the position it would have been in if the duty had been met.
For example, the Insurer may:
•
avoid the cover (treat it as if it never existed);
•
vary the amount of the cover; or
•
vary the terms of the cover.
Whether the Insurer can exercise one of these remedies
depends on a number of factors, including:
•
whether reasonable care was taken not to make a
misrepresentation. This depends on all of the relevant
circumstances;
•
what the Insurer would have done if the duty had been met
– for example, whether it would have oered cover, and if
so, on what terms;
•
whether the misrepresentation was fraudulent; and
•
in some cases, how long it has been since the cover started.
Before any of these remedies are exercised, the Insurer will
explain the reasons for its decision, how to respond and provide
further information, and what you can do if you disagree.
Guidance for answering the questions in this form
You are responsible for the information provided to the
Insurer. When answering questions, please:
•
Think carefully about each question before you answer.
If you are unsure of the meaning of any question, please
ask us before you respond.
•
Answer every question.
•
Answer truthfully, accurately and completely. If you are
unsure about whether you should include information,
please include it.
•
Review your application carefully before it is submitted.
If someone else helped prepare your application (for
example, your adviser), please check every answer (and if
necessary, make any corrections) before the application is
submitted.
Please note that there may be circumstances where the
Insurer later investigates whether the information given to it
was true. For example, it may do this when a claim is made.
Changes before your cover starts
Before your cover starts, the Insurer may ask you whether
the information that has been given as part of your
application for insurance remains accurate or whether there
has been a change to any of your circumstances. As any
changes might require further assessment or investigation,
it could save time if you let us or the Insurer know about any
changes when they happen.
If you need help
It’s important that you understand your obligations and the
questions that are being asked. Please contact us for help if
you have diculty understanding the process of obtaining
insurance or answering any questions.
Please also let us know if you’re having diculty due to a
disability, understanding English or for any other reason –
we’re here to help and can provide additional support.
3.2 Your salary and occupation details
Provide your salary if you want to apply for more cover or to change your individual work rating*.
Annual (before-tax) salary, excluding employer super contributions
$
, , .
0 0
Provide your occupation if you want to apply to change your individual work rating*.
Job title/occupation
Average number of hours you work in your main occupation
hours a week
* If you’re a Public Sector Division member, your work rating only applies to Income Protection. GHD Superannuation Plan members automatically receive a
White Collar work rating.
Please return this completed form to: AustralianSuper, GPO Box 1901, MELBOURNE VIC 3001
or upload a scanned copy of your completed form to us via our website at australiansuper.com/email
Questions? Telephone 1300 300 273 Web australiansuper.com
4. START YOUR AGE-BASED COVER
If you’ve turned 25, you can choose to start your age-based cover, even if your account balance hasn’t reached $6,000.
You should read the Insurance in your super guide for your division for important information about when your cover will start.
Please print (
✗) next to each type of age-based cover you want to start.
Death
TPD
Income Protection
If you haven’t turned 25 you’re not eligible for age-based cover, but you can apply for extra (fixed) or fixed Death and/or TPD
cover by completing section 5, or fixed Income Protection by completing section 6. For more information about your cover
options, read the Insurance in your super guide for your division at australiansuper.com/InsuranceGuide
5. DEATH AND TPD COVER
Complete this ection to apply for cover or change your existing cover (increase or reduce). You can:
a) apply for age-based cover
b) apply for or change your extra (fixed) cover
c) apply for or change your fixed cover (includes switching your age-based cover to fixed cover), or
d) remove multiples of cover (see the Insurance in your super guide for your division for details about multiples and how much
cover you’ll get).
If you apply to make any changes to your Death and/or TPD cover and your application is accepted, your basic cover will
start automatically even if your super balance hasn’t reached $6,000*. Any extra (fixed) or fixed cover will start automatically
regardless of your super balance or age.
There’s no limit on the amount of Death cover you can apply for and for TPD the limit is $3 million. Print (✗) to confirm what you want.
Cover designs Type of cover Cover in $1,000 amounts
a) Age-based cover
Age-based Death*
Age-based TPD*
Your cover amount will be based on your age*.
b) Extra (fixed) cover
Extra Death
Extra TPD
†
$ , ,
0
0
0
$
, ,
0
0
0
Write the amount you want added to
your age-based cover.
Cover designs Type of cover Cover in $1,000 amounts
c) Fixed cover
Fixed Death
Fixed TPD
†
$ , ,
0
0
0
$
, ,
0
0
0
Write the amount of fixed cover you
want. If you have age-based cover it’ll
be replaced with fixed cover.
Cover designs Type of cover
d) Remove my multiple
Death
TPD
If your multiple is greater than 1.0 your age-based cover will reduce to the
basic cover amount and any extra (fixed) cover you have will stay the same.
If it is less than 1.0 your total cover amount (and any extra cover you have)
will be fixed
†
.
* Age-based Death and TPD cover will start when you turn 25 (if you’re eligible).
† Any amount of fixed TPD cover will reduce gradually from age 61 to zero at age 65, unless you’re a Public Sector Division member.
You may need to complete the Health Questions. Go to section 8 to check.
20742 09/21 page 4 of 12
Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 Trustee of AustralianSuper ABN 65 714 394 898
6. INCOME PROTECTION
Complete this section to apply for or change to fixed Income Protection. If you apply for fixed Income Protection and your
application is accepted, your cover will start automatically even if you haven’t turned 25 and your super balance hasn’t
reached $6,000.
The amount of Income Protection you can apply for is limited to 85% of your monthly salary. Up to 75% is paid to you and up to
10% to your super.
Salary is your annual (before-tax) salary, excluding employer super contributions.
Here’s an example to help you work out the maximum amount of Income Protection you can apply for.
Ben earns $78,000 a year (before-tax), excluding employer super contributions. The maximum cover amount he
can apply for is:
$78,000 x 0.85
= $5,525 a month
Ben can apply for cover up to $5,600 a month.
12 (months) (rounded up to the nearest $100)
If you’re eligible for payments, your monthly benefit will be based on your salary before you were injured or ill
(pre-disability income) and other factors. For more information, see the Insurance in your super guide for your division
at australiansuper.com/InsuranceGuide
Print (✗) below to confirm what you want.
Cover options Cover in $100 amounts
Age-based Income Protection*
Your cover amount will be based on your age
*
.
Fixed Income Protection
$
,
0
0
a month
Write the amount of fixed cover you want. If you have
age-based cover it’ll be replaced with fixed cover.
* Age-based Income Protection will start when you turn 25 (if you’re eligible)
You may need to complete the Health Questions. Go to section 8 to check.
6.1 Waiting period and benefit payment period
Complete this section to change your waiting period and/or benefit payment period. If you change your waiting period, your basic
cover will start automatically even if your super balance hasn’t reached $6,000*. Any fixed cover will start automatically regardless
of your age and super balance.
* Age-based Income Protection will start when you turn 25 (if you’re eligible).
The cost of your cover will depend on your waiting period and benefit payment period (as well as your individual work rating).
For more information and the dierent costs download the Insurance in your super guide for your division at
australiansuper.com/InsuranceGuide
Print (✗) below to confirm what you want.
Waiting
period
This is the minimum time you must wait before you’ll start receiving an Income Protection
benefit payment (as long as you’re eligible). Payments are made one month in arrears. If
you’re applying for Income Protection your waiting period will be 60 days. You can change
your waiting period to 30 days. A shorter waiting period will cost more.
Your new waiting period is eective from the date we accept your application plus the number of days
of your current waiting period. For example if you change your waiting period from 60 days to 30 days
and then you claim within 30 days of making the change, you’ll need to complete a 60 day waiting period.
30 days
60 days
Benefit
payment
period
This is the maximum length of time that payments may be made if you’re temporarily unable
to work due to illness or injury.
Depending on your occupation
†
you can apply for a benefit payment period of up to five
years or up to age 65. A longer benefit payment period will cost more. If you’re applying for
Income Protection and you don’t make a choice, your benefit payment period will be up to
two years.
†
There are some occupations where you can’t have a benefit period of up to five years or up to age 65.
These occupations are listed at australiansuper.com/occupations
Up to two years
Up to five years
Up to age 65
You may need to complete the Health Questions. Go to section 8 to check.
20742 09/21 page 5 of 12
Please return this completed form to: AustralianSuper, GPO Box 1901, MELBOURNE VIC 3001
or upload a scanned copy of your completed form to us via our website at australiansuper.com/email
Questions? Telephone 1300 300 273 Web australiansuper.com
7. CHANGE YOUR INDIVIDUAL WORK RATING
A work rating classifies the usual activities of your job into one of three ratings: Blue Collar, White Collar or Professional. Your
work rating is one of the factors that determines how much you pay for your insurance cover. You could pay less for your
insurance cover if your work is rated as White Collar or Professional.
Tell us your occupation (in section 3.2) and complete the questions below to apply to change your individual work rating to
White Collar or Professional.*
1. Are the usual activities of your job ‘white collar’? Yes
No
This means:
•
you spend more than 80% of your job doing clerical or administrative activities in an oce-based environment, or
•
you’re a professional using your university qualification in a job that has no unusual work hazards
(some examples of unusual work hazards include: working underground, working underwater,
working at heights or working in the air).
2. Are you earning $100,000 or more a year from your job? Yes
No
3. Do you have a university qualification? Yes
No
4. Do you have a management role in your company? Yes
No
* If you’re a Public Sector Division member, your work rating only applies to Income Protection. If you’re a GHD member you’re automatically provided with a
White Collar individual work rating.
8. HEALTH QUESTIONS
Complete this section if you’re:
•
applying for cover
•
applying to increase your cover amount
•
applying for an Income Protection benefit payment period of up to five years or up to age 65, or
•
aged 63 or 64 and reducing your Income Protection benefit payment period to two years (which means you’re extending your
cover to age 70).
You don’t need to complete health questions if your cover amount is decreasing, your cover amount is unchanged (for
example you switch from age-based to fixed cover), or you’re only changing your Income Protection waiting period.
1. Has an application for life, disability, trauma, accident or illness insurance on your life ever been declined,
deferred or accepted with a loading, exclusion or special terms? If Yes please provide details below. Yes
No
Insurance company name Date Terms oered and reason
2. Are you claiming or have you ever claimed a benefit from any source (e.g. Total & Permanent Disablement benefit from any
Superannuation Fund, Workers’ Compensation, Disability pension, Veterans’ Aairs or any other insurance policy providing
accident or illness benefits)?
If Yes please provide details below.
Yes
No
Benefit type/source/reason for claim
Claim date Claim amount Date claim finalised
$
Benefit type/source/reason for claim
Claim date Claim amount Date claim finalised
$
20742 09/21 page 6 of 12
Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 Trustee of AustralianSuper ABN 65 714 394 898
8. HEALTH QUESTIONS (CONTINUED)
Height (cm) (ft/in) Weight (kg) (st/lb)
3. What’s your height and current weight?
OR
OR
4. Are you currently o work due to injury or illness, or restricted from being capable of performing your
full and normal duties on a full-time basis (for at least 30 hours a week), even if your actual employment
is on a part-time or casual basis? Yes
No
5. Have you in the last year had medication prescribed by a medical practitioner that is intended to be used
for three months or longer (excluding contraceptives and treatment for hay fever, hair loss and acne)? Yes
No
6. Have you been unable to work because of injury or illness (excluding pregnancy) for more than two
consecutive weeks in the last three years? Yes
No
7. Have you ever had or received medical advice or treatment (including surgery) for any of the
following conditions:
a) Chest pain, high blood pressure, raised cholesterol or any heart/circulatory disorder? Yes
No
b) Stroke, paralysis, epilepsy, multiple sclerosis or any blood or neurological condition? Yes
No
c) Diabetes, hepatitis, or any condition of the thyroid, liver, kidneys, prostate or urinary bladder? Yes
No
d) Asthma, sleep apnoea, respiratory or any other lung condition (other than the common cold)? Yes
No
e) Any injury, disease or disorder of the back, neck, knee, shoulder or other joint, bone, muscle,
tendon or ligament condition, including arthritis or gout? Yes
No
f) Depression, anxiety, chronic tiredness or fatigue, panic attacks, post-traumatic stress, or any
other behavioural, mental or nervous condition? Yes
No
g) Cancer, tumour, melanoma, sun spot, mole or malignant growth of any kind? Yes
No
h) Drug dependence or abuse (either prescribed or non-prescribed), or alcohol dependence or abuse? Yes
No
i) Hernia, gall bladder, bowel or stomach condition (other than constipation, upset stomach, diarrhoea,
or gastro where these were short, isolated episodes from which you have made a full recovery)? Yes
No
j) Any condition of the eyes causing visual impairment (partial or complete loss of sight that can’t be
corrected by glasses, contact lenses or laser eye surgery) or impaired hearing or tinnitus? Yes
No
8. Have you been infected with the Human Immunodeficiency Virus (HIV) or tested positive for
Acquired Immune Deficiency Syndrome (AIDS)? Yes
No
9. Apart from any condition already disclosed, do you plan to seek or are you awaiting medical advice,
investigation or treatment for any other current health condition or symptoms? Yes
No
20742 09/21 page 7 of 12
Please return this completed form to: AustralianSuper, GPO Box 1901, MELBOURNE VIC 3001
or upload a scanned copy of your completed form to us via our website at australiansuper.com/email
Questions? Telephone 1300 300 273 Web australiansuper.com
PART TWO: DETAILED HEALTH STATEMENT
Complete this section if you answer Yes to any of the questions below:
•
Will your total Death or TPD cover exceed $800,000 if this application is accepted?* Yes
No
•
Will your total Income Protection exceed $10,000 a month if this application is accepted? Yes
No
•
Are you applying for an Income Protection benefit payment period of up to five years or up to age 65? Yes
No
•
Have you answered Yes to any of the questions in section 8 (Q1 to Q9)? Yes
No
If you answer No to all of the above questions, please read, then sign and date the Declaration in section 15.
* The Insurer may require medical evidence based on your age, amount of cover or health history. This may involve a medical exam or test which the
Insurer will pay for.
9. ACTIVITIES AND PASTIME DETAILS
Do you currently, or do you intend to engage in any hazardous pastime and/or sporting activity such
as aviation (other than as a fare paying passenger on a commercial airline), football, scuba diving,
motor sports, trail bike riding or rock climbing? Yes
No
If Yes, provide further details below:
What are the activities you engage in?
At what level do you participate?
Recreational only (non-competition)
Recreational with competition
Semi-professional/professional
Number of times you participate on average in these activities a year (for example
hours flown, number of drives, events)
Do you receive any income from participating in these activities? Yes
No
Maximum depth or speed reached (if applicable)
10. PERSONAL HEALTH DETAILS
1. Have you smoked in the last 12 months? Yes
No
If Yes, please indicate type (for example cigarettes or cigars) and average amount smoked in one of the following boxes.
Substance smoked A day A week A year
2. In the last five years have you smoked any substance other than tobacco? Yes
No
If Yes, please indicate substances smoked, frequency of use, date first smoked and when last smoked.
Substance smoked Frequency Date first smoked Date last smoked
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
3. Do you drink alcohol? Yes
No
If Yes, please provide the average number of standard drinks you consume (one standard drink is:
a nip of spirits, a glass (150ml) of wine, a pot (285ml) of beer).
A day A week A year
4. In the last five years have you engaged in any activity reasonably expected to having an increased
risk of exposure to the HIV/AIDS virus (this includes unprotected anal sex, sex with a sex worker or
sex with someone you know, or suspect to be HIV positive)? Yes
No
If Yes, we will contact you to complete a confidential questionnaire.
20742 09/21 page 8 of 12
Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 Trustee of AustralianSuper ABN 65 714 394 898
20742 09/21 page 9 of 12
11. FAMILY HISTORY
Has any of your immediate family (mother, father, brother or sister) been diagnosed with any of the following conditions before
the age of 60: Heart disease (e.g. angina or heart attack), stroke, cardiomyopathy, cancer, diabetes, mental illness, Alzheimer’s
disease, multiple sclerosis, muscular dystrophy, Parkinson’s disease, polycystic kidney disease, Huntington’s disease or any
other inherited blood or neurological disorder?
Unknown
No – go to section 12
Yes – complete the following table
Relationship to member Condition (e.g. Type 2 diabetes, breast cancer)
Approximate
age of onset
Age at death
(if applicable)
12. DOCTOR DETAILS
1. What’s the name and address of the last doctor or medical centre you visited?
Full name of doctor or medical centre
Street address and suburb State Postcode
Telephone Facsimile
2. a) What was the date of your last consultation?
Within the last month
7 - 12 months ago
1 - 3 months ago
12 months to 2 years ago
4 - 6 months ago
Over 2 years ago
b) What was the reason for your consultation? (Please specify a reason for the consultation)
c) What was the result/outcome from your last consultation?
Referral to specialist/health professional
Ongoing treatment (for example ventolin inhaler)
Tests conducted – results pending
Routine tests conducted – results all clear/normal
Not fully recovered yet
All clear/normal/full recovery – no tests or prescribed
treatment required (other than contraceptive and
cold/flu medication)
3. Is the doctor/medical centre mentioned above your usual doctor/medical centre? Yes
No
Please return this completed form to: AustralianSuper, GPO Box 1901, MELBOURNE VIC 3001
or upload a scanned copy of your completed form to us via our website at australiansuper.com/email
Questions? Telephone 1300 300 273 Web australiansuper.com
20742 09/21 page 10 of 12
13. GENERAL HEALTH QUESTIONNAIRE
If you have answered Yes to Questions 4 to 9 in section 8, please complete the table below.
Please ensure you write the question number in the box above each column.
Question number
Question number Question number
1. Name of condition
2. Date symptoms first started
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
3. Date symptoms ceased
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
(if ongoing please state) Yes
No
Yes
No
Yes
No
4. How often do/did you have symptoms?
Please choose one of the following
daily, weekly, monthly, quarterly,
half-yearly, yearly, one-o, other.
5. Severity of condition
Please choose from one of the following
mild, moderate, severe, never had
symptoms, symptoms ceased.
6. Did you take medication or have you had
any other treatment (ie physiotherapy
or an operation) for this condition? Yes
No
Yes
No
Yes
No
If Yes, name the treatment/condition:
7. Are you still on treatment,
including medication? Yes
No
Yes
No
Yes
No
8. Have you ever been o work
due to this condition? Yes
No
Yes
No
Yes
No
Details (if there is insucient space
please attach an additional sheet)
If Yes, please state the total time o work?
Date from:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Date to:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
9. Have you had any residual, ongoing eects
or restrictions as a result of this condition? Yes
No
Yes
No
Yes
No
If Yes, please provide details and dates:
Date from:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Date to:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
10. Is your treating doctor dierent from
your usual doctor? Yes
No
Yes
No
Yes
No
If Yes, please provide doctor’s details:
Full name of doctor
Address (street/state/postcode)
Phone and fax number
Full name of doctor
Address
(street/state/postcode)
Phone and fax number
Full name of doctor
Address (street/state/postcode)
Phone and fax number
Issued by AustralianSuper Pty Ltd ABN 94 006 457 987 AFSL 233788 Trustee of AustralianSuper ABN 65 714 394 898
A. Asthma and bronchitis or any other lung
complaint questionnaire
a) Name of condition
b) Have you been diagnosed within
the last 12 months? Yes
No
c) Frequency of symptoms in the last five years
Daily
Weekly
Occasionally
One-o episode
None – childhood only
d) Severity of symptoms in the last five years:
Nil symptoms – childhood only
Mild ie exercise-induced only, seasonal
(related to hay fever allergy, colds or flu)
Moderate (ie all year round, specific triggers)
Severe (ie constant, reduced lung capacity,
restriction of lifestyle or work duties)
e) Have you required over the last five years:
Daily preventative inhalers, such as ventolin Yes
No
Occasional use of a nebuliser or oral steroid
medication eg prednisolone Yes
No
Hospitalisation/emergency treatment Yes
No
f) Maximum number of consecutive days o
work/school you have had over the last two
years due to this condition?
Number of days
g) Is your treating doctor dierent from your
usual doctor? Yes
No
If Yes, please complete details below:
Full name of doctor
Street address
Suburb State Postcode
Phone number
Fax number
B. Joint/musculoskeletal questionnaire
If applying for Death only cover complete Questions a) and b) only.
If applying for TPD or Income Protection, complete all questions.
a) Nature of complaint (doctor’s diagnosis), ie sciatica, back
pain, broken bone
b) Location of complaint, eg lower back, right knee, sciatic nerve
c) When did symptoms first begin?
D
D
M
M
Y
Y
d) Cause of condition, eg lifting, car accident, fall in workplace,
unknown
e) Was an x-ray or scan taken?
No
Go to Question f
Yes
Complete below
Date of tests taken
D
D
M
M
Y
Y
Details of results of tests taken
f) Is the nature of the condition
degenerative or a disc problem? Yes
No
g) Are you still undergoing treatment
or experiencing symptoms? Yes
No
If No, complete below:
Date symptoms ceased
D
D
M
M
Y
Y
Date treatment ceased
D
D
M
M
Y
Y
h) Have you ever been o work as a result of
this complaint or been unable to perform
your normal day-to-day activities? Yes
No
If Yes, please indicate period/s o work:
Date from Date to
D
D
M
M
Y
Y
D
D
M
M
Y
Y
i) Do you have any residual, ongoing eects
or restrictions as a result of this condition? Yes
No
If Yes, please provide dates and details
j) Is your treating doctor dierent from
your usual doctor?
Yes
No
If Yes, complete below:
Full name of doctor
Street address
Suburb State Postcode
Phone number
Fax number
14. SPECIFIC HEALTH QUESTIONNAIRE
Please complete relevant questionnaire below if you have answered Yes to either Question 7d) or 7e) in section 8.
20742 09/21 page 11 of 12
Please return this completed form to: AustralianSuper, GPO Box 1901, MELBOURNE VIC 3001
or upload a scanned copy of your completed form to us via our website at australiansuper.com/email
Questions? Telephone 1300 300 273 Web australiansuper.com
15. DECLARATION
This section must be completed in all circumstances.
I authorise:
•
The Insurer to refer any statements that have been made in
connection with my application for cover and any medical
reports to other entities involved in providing or administering
the insurance (for example reinsurers, medical consultants, legal
advisers).
•
The Insurer and any person appointed by the Insurer to obtain
relevant information on my financial history from the Insurance
Reference Association and any other body holding information
on me.
For information on the Insurer’s privacy and information handling
practices, read their Privacy Policy Statement at tal.com.au or
call 1300 209 088 for a copy.
I declare that:
•
I’ve read and understood TAL’s Privacy Policy and I agree with
how TAL will collect, use and disclose my personal information.
•
The answers to all the questions and the declarations on
this form are true and correct (including those not in my
own handwriting).
•
I’ve read and understood the Product Disclosure
Statement, and the Insurance in your super guide at
australiansuper.com/InsuranceGuide and understand that
the additional information referred to in the guide is also
part of the Product Disclosure Statement
•
If I’m a Public Sector Division member I understand that the
individual work rating will only apply to my Income Protection.
•
I’ve read the Privacy Collection Statement as set out below,
and I understand how AustralianSuper will use my personal
information. To the best of my knowledge, the information I have
provided on this form is correct.
•
If I’ve provided my email address and/or phone number,
I consent to AustralianSuper sending me information about my
account, AustralianSuper’s products and services and marketing
communications, including third-party products and services,
via email, my online account, SMS, mobile app or phone, as
appropriate and in accordance with AustralianSuper’s Privacy
Policy. I understand I can change my communication preferences
at any time by calling AustralianSuper on
1300 300 273 or
through the My communication preferences section of my online
account.
A summary of AustralianSuper’s Privacy Collection Statement is at
the end of this form. Our Privacy Collection Statement and Privacy
Policy may change from time to time. The latest versions will be
available online at australiansuper.com/CollectionStatement and
australiansuper.com/privacy
I acknowledge that:
•
My eligibility to claim for benefits will be determined by the
Insurer in line with AustralianSuper’s insurance policy terms and
conditions
•
Insurance cover will only be provided on the terms and
conditions set out in the contract of insurance with the Insurer
and as agreed between AustralianSuper and the Insurer from
time to time.
•
The answers I’ve provided, together with any special conditions,
will form the basis of my insurance cover.
•
If I fix any of my cover, I understand that my cover amount won’t
change (except TPD cover reduces gradually from age 61 to zero
at age 65, unless I’m a Public Sector Division member) but the
cost will increase with age.
•
If I’ve chosen to start my cover, the cost of it will be deducted
monthly from my super account, once the cover starts.
•
If I’ve applied to make any changes to my cover (including changing
my waiting period), and my application is accepted, my cover
will start automatically even if I haven’t turned 25 and my super
balance hasn’t reached $6,000. Age-based cover will start when
I turn 25 (if I’m eligible). This means that the cost of my cover will
also start to be deducted monthly from my super account.
•
If I’ve chosen to cancel any of my cover, I’ll no longer be insured
for that cover, and:
– I (or my beneficiaries) won’t be able to make an insurance
claim if something happens after I cancel.
– The cost of cover will stop being deducted from my super
account (costs are deducted one month in arrears).
– I might not be able to get cover later. If I decide to reapply I’ll
need to provide health information for the Insurer to consider.
– If I’m replacing this cover with another insurance policy, I’ll
wait until the other insurer confirms my cover has started.
– I’ve considered getting financial advice to help work out if
cancellation is right for me.
•
A photocopy of this authorisation is as valid as the original
•
Any change in cover will start from:
– the date the change is accepted by the Insurer (as long as my
employer is paying super contributions) or
– the date I receive confirmation that my cover has started or
re-started (and it hasn’t stopped again)
whichever is the later date.
Privacy Collection Statement
Please read this Privacy Collection Statement to see how AustralianSuper uses your personal information.
AustralianSuper Pty Ltd (ABN 94 006 457 987) of GPO Box 1901, Melbourne, Victoria 3001, collects your personal information (PI) to
run your super account (including insurance), improve our products and services and keep you informed. If we can’t collect your PI we
may not be able to provide these services. PI is collected from you but sometimes from third parties like your employer. We will only
share your PI where necessary to perform our activities with our administrator (Australian Administration Services Pty Ltd, Link Group),
service providers, as required by law or court/tribunal order, or with your permission. Your PI may be accessed overseas by some of
our service providers. A list of countries can be found at the URL below. Our Privacy Policy details how to access and change your PI,
as well as the privacy complaints process. For complete details go to australiansuper.com/privacy or call us on 1300 300 273.
Sign here:
Date
D
D
M
M
2
0
Y
Y
Print full name
20742 09/21 page 12 of 12
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Completed 20 April 2022

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