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
