(Office use only)
GUARANTEED ANNUITIES
LIFESTREAM GUARANTEED INCOME
CHANGE OF DETAILS FORM
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Instructions/information on how to complete this form
Please complete this form using BLACK or BLUE INK in CAPITAL LETTERS. Mark appropriate answer boxes with a tick ().
Fields marked with an asterisk (*) must be completed for the purposes of anti-money laundering and counter-terrorism financing
laws and the Foreign Account Tax Compliance Act (FATCA).
SECTION 1 – PERSONAL DETAILS OR COMPANIES/TRUSTS AND FUNDS DETAILS
Policy number
Policy Owner
Title
Mr Mrs Ms Miss Other
}
Given name(s)*
Surname*
Full Company/Trust/Fund Name*
Address*
State Postcode Country
Date of birth*
DD / MM / YYYY
Telephone Mobile phone number
Joint Policy Owner
Title
Mr Mrs Ms Miss Other
}
Given name(s)*
Surname*
Address*
State Postcode Country
Date of birth*
DD / MM / YYYY
Telephone Mobile phone number
SECTION 2 – CHANGE OF ADDRESS
For security purposes please ensure both existing and new details are completed.
Existing Residential address (PO Box is NOT acceptable)*
State Postcode Country
Existing Mailing address (if different to above)
State Postcode Country
SAVE FORM
PRINT FORM
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commbank.com.au I Phone: 13 1056 I Fax: 1300 852 094 I Mail: CommInsure Guaranteed Annuities PO Box 320 Silverwater NSW 2128
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809, AFSL 235035 (CMLA). CommInsure is a registered business name of CMLA.
Thank you for completing this form
21122_CS/0415 CIL1758 150615
SECTION 2 – CHANGE OF ADDRESS (CONTINUED)
New Residential address (PO Box is NOT acceptable)*
State Postcode Country
New Mailing address
(if different to above)
State Postcode Country
Telephone Mobile phone number Email
TFN ABN/ACN
SECTION 3 – CHANGE OF NAME
If your name has changed, please attach a copy certified by a justice of the peace, solicitor or notary public of the documentation by
which you registered your change of name, such as a Marriage Certificate, Deed Poll or Decree nisi (in the event of divorce).
Policy Owner
Title
Mr Mrs Ms Miss Other
}
Given name(s)*
Surname*
Full Company/Trust/Fund Name
TFN/ACN
Old Signature
New Signature
Please print name
Joint Policy Owner
Title
Mr Mrs Ms Miss Other
}
Given name(s)*
Surname*
TFN
Old Signature
New Signature
Please print name
SECTION 4 – CHANGE OF BANK ACCOUNT DETAILS
Please provide details of your account you want your regular payments to be credited to. The account name must be in the name
ofthe investor.
Name of Australian financial institution
Account name Branch number (BSB) Account number
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commbank.com.au I Phone: 13 1056 I Fax: 1300 852 094 I Mail: CommInsure Guaranteed Annuities PO Box 320 Silverwater NSW 2128
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809, AFSL 235035 (CMLA). CommInsure is a registered business name of CMLA.
Thank you for completing this form
Page 2 of 3
SECTION 5 – CHANGE OF ONGOING ADVISER SERVICE FEE
I/We wish to cease the Ongoing Adviser Service Fee (ASF) arrangement on my policy
I/We wish to vary the Ongoing ASF arrangement on my policy as indicated below:
I/We authorise CommInsure to pay my/our adviser
An Ongoing ASF
$
(incl. GST) of gross regular payments (no more than 2 decimal places)
Any amount of Ongoing ASF indicated above will be deducted from your after-tax regular payment at the same frequency as your
regular payments.
All Ongoing ASFs are paid to your financial adviser in accordance with the arrangements we have in respect of that adviser.
If the payment is split between two financial advisers, please complete the table below:
Name of financial adviser Allocation of amount
Primary
Secondary
Primary adviser name Adviser AFSL number
Adviser group name
Phone number Email
Signature of adviser Date
DD / MM / YYYY
Secondary adviser name Adviser AFSL number
Adviser group name
Phone number Email
Signature of adviser Date
DD / MM / YYYY
SECTION 6 – DECLARATION
1. If this form is signed under a Power of Attorney, the attorney certifies that he/she has not received notice of revocation of that
Power. A certified copy of the Power of Attorney should be submitted with this form unless already sighted by CMLA.
2. I/We declare that the information provided in this form is correct and complete.
Signature of Policy Owner Date
DD / MM / YYYY
Signature of Joint Policy Owner Date
DD / MM / YYYY
Signature of Director/Company officer/Trustee Date
DD / MM / YYYY
This form must be mailed to: CommInsure, PO Box 320 Silverwater NSW 2128,
Contact phone number: 13 1056 between 8.30am and 6.00pm, Monday to Friday (Sydney time).
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commbank.com.au I Phone: 13 1056 I Fax: 1300 852 094 I Mail: CommInsure Guaranteed Annuities PO Box 320 Silverwater NSW 2128
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809, AFSL 235035 (CMLA). CommInsure is a registered business name of CMLA.
Thank you for completing this form
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