INVESTMENT GROWTH BOND APPLICATION FORM
Before you sign this Application, you must read the Product Disclosure Statement
(PDS) dated 1 November 2019. The PDS will help you to understand the product and
decide whether it’s appropriate to your needs.
Policy No:
Office Use Only
All Applicants need to complete this section and Section 5.
If there is more than one Applicant, they will own the policy as joint tenants.
If the Applicant is a child between 10 and 16 years old then please ensure Section 4 is completed.
If this Application is for a Child Advancement Policy then please ensure both Sections 2 and 3 are completed.
SECTION 1 - APPLICANT(S) DETAILS
Please write in BLOCK letters and use a black ballpoint pen. 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). In this Application,
‘you’ and ‘I/we’ refers to the proposed Applicant(s) or Life/Lives Insured or both as indicated.
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
INVESTMENT GROWTH BOND
APPLICATION FORM.
1. For Company, Fund or Trust applications, please complete the appropriate Anti-Money Laundering and Counter Terrorism Financing form that can be
downloaded from commbank.com.au/igb or contact us on 1800 624 100 to request a copy.
003-886 011119 (BRC25)
Is the investor an individual?
Is this a Child Advancement Policy?
Yes
Yes
No
Complete below or
Complete only one Bond Owner in Section 1 and one Life Insured in Section 2.
Go to Company, Fund or Trust details on page 36
1
Given name(s)* Given name(s)*
For sole trader, full business name* (where applicable) For sole trader, full business name* (where applicable)
Surname* Surname*
Home phone number Home phone number
Mobile Mobile
Email address Email address
Date of birth* Date of birth*Gender Gender
/ / / /
Female FemaleMale Male
Occupation and position title (please specify if retired)* Occupation and position title (please specify if retired)*
For sole traders, ABN (if any)* For sole traders, ABN (if any)*
Residential/Business address* (PO Box is not acceptable) Residential/Business address* (PO Box is not acceptable)
State StatePostcode PostcodeCountry Country
Mailing address Mailing address
State StatePostcode PostcodeCountry Country
Other OtherMr MrMs MsMrs MrsMiss Miss
Bond Owner 1 (‘Applicant 1)
Bond Owner 2 (‘Applicant 2’) (N/A for Child Advancement Policy)
Source of funds* (e.g sale of property, accumulated savings) Source of funds* (e.g sale of property, accumulated savings)
35Investment Growth Bond
Bond Owner 1 (‘Applicant 1’) Bond Owner 2 (‘Applicant 2’)
Investor – Company, Fund or Trust
1
Investor – Company, Fund or Trust
1
Company/Fund/Trust name* Company/Fund/Trust name*
Type of Investor* Type of Investor*
Company Fund Trust Company Fund Trust
Principal business/trust activity* Principal business/trust activity*
Country established, if not Australia*
Source of funds* (e.g sale of property, accumulated savings) Source of funds* (e.g sale of property, accumulated savings)
Country established, if not Australia*
Phone number Phone numberABN* ABN*
Are you a charity?* No
Yes Are you a charity?* No Yes
Business address* (PO Box is not acceptable) Business address* (PO Box is not acceptable)
Mailing address Mailing address
State StatePostcode PostcodeCountry Country
State StatePostcode PostcodeCountry Country
Given name(s)* Given name(s)*
Contact Person Contact Person
Home phone number Home phone number
Mobile Mobile
Email address Email address
Surname* Surname*
SECTION 1 - APPLICANT(S) DETAILS
1. For Company, Fund or Trust applications, please complete the appropriate Anti-Money Laundering and Counter Terrorism Financing form that can be downloaded from
commbank.com.au/igb or contact us on 1800 624 100 to request a copy.
003-886 011119 (BRC25)
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
36 Investment Growth Bond
INVESTMENT GROWTH BOND APPLICATION FORM
SECTION 2 - LIFE/LIVES INSURED
The Investment Growth Bond is a life insurance policy. For Child Advancement Policies the child must be listed as the Life Insured
and only one Life Insured may be nominated.
Life Insured 1 Life Insured 2 (N/A for Child Advancement Policy)
Home phone number Home phone numberMobile Mobile
The Life/Lives insured cannot be altered once the policy has commenced.
The Death Benefit Guarantee is based on the death of the life/lives insured not the Bond owner(s).
Residential address* (PO Box is not acceptable) Residential addr
ess* (PO Box is not acceptable)
Mailing address Mailing address
State StatePostcode PostcodeCountry Country
State StatePostcode PostcodeCountry Country
Other OtherMr MrMs MsMrs MrsMiss Miss
Date of birth* Date of birth*
/ / / /
Gender Gender
Female Female
Male Male
Complete this section if you wish to set up a Child Advancement Policy and the child is under 16 years old.
Please note, only one child may be nominated as the Life Insured and only one Bond Owner can apply.
The Bond Owner should also provide details in Section 1.
I declare that the Policy issued on the basis of this Application on the life of
shall be a Child Advancement Policy in accordance with the provisions of the Life Insurance
Act 1995 and on the child’s (10
th
– 25
th
)
birthday shall become the absolute property of the child (please note where
no vesting age is nominated, the transfer will occur when the child turns 25).
Please note that this will be shown on the certificate exactly as it is written above. The certificate will be issued with the policy
Welcome Letter.
To
From
Is the Child Advancement Policy a gift, tick () if you would like a certificate to be issued?
Please provide the following information to be shown on the certificate (please print clearly):
/ /
Date of birth
SECTION 3 - CHILD ADVANCEMENT POLICY
Given name(s)* Given name(s)*
Surname* Surname*
Email address Email address
Yes
/ /
Date
Signature of Bond Owner
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
003-886 011119 (BRC25))
37Investment Growth Bond
SECTION 5 - FATCA AND TAX RESIDENCY
This consent is not required for a Child Advancement Policy.
This section must be completed by the parent/guardian if the Bond Owner is age 10 or more, but less than age 16.
I,
as a parent/guardian of
hereby consent to this Application on the life of
SECTION 4 - PARENTAL/GUARDIAN CONSENT STATEMENT
Signature of parent(s)/guardian(s)
/ /
Date
Signature of parent/guardian 1
Signature of parent/guardian 2
Please answer both tax residency questions:
Please answer both tax residency questions:
If the individual is a tax resident of a country other than Australia, please provide their tax identification number (TIN) or equivalent below. If
they are a tax resident of more than one other country, please list all relevant countries below.
A TIN is the number assigned by each country for the purposes of administering tax laws. This is the equivalent of a Tax File Number in
Australia or a Social Security Number in the US. If a TIN is not provided, please list one of the three reasons specified (A, B or C) for not
providing a TIN.
If the individual is a tax resident of a country other than Australia, please provide their tax identification number (TIN) or equivalent below. If
they are a tax resident of more than one other country, please list all relevant countries below.
A TIN is the number assigned by each country for the purposes of administering tax laws. This is the equivalent of a Tax File Number in
Australia or a Social Security Number in the US. If a TIN is not provided, please list one of the three reasons specified (A, B or C) for not
providing a TIN.
Bond Owner 1
Bond Owner 2
Is the investor a resident of Australia?*
Is the investor a resident of Australia?*
Yes
Yes
No
No
Is the individual a tax resident of another country?*
Is the individual a tax resident of another country?*
Yes
This Section is mandatory to complete as part of your application, the questions marked with an (*) must be completed.
Tax Residency rules differ by country. Whether an individual is a tax resident of a particular country is often (but not always) based
on the amount of time a person spends in a country, the location of a person’s residence or place of work. For the US, tax residency
can also be as a result of citizenship or residency.
If no TIN list reason:
A. The country of tax residency
does not issue TINs to tax
residents
B. The individual has not been
issued with a TIN
C. The country of tax residency
does not require the TIN to
be disclosed
1. Country TIN
If no TIN,
list reason
A, B or C
2. Country TIN
If no TIN,
list reason
A, B or C
3. Country
TIN
If no TIN,
list reason
A, B or C
If there are more countries, provide details on a separate sheet and tick this box
If no TIN list reason:
A. The country of tax residency
does not issue TINs to tax
residents
B. The individual has not been
issued with a TIN
C. The country of tax residency
does not require the TIN to
be disclosed
1. Country TIN
If no TIN,
list reason
A, B or C
2. Country TIN
If no TIN,
list reason
A, B or C
3. Country
TIN
If no TIN,
list reason
A, B or C
If there are more countries, provide details on a separate sheet and tick this box
No
Complete below
Yes
No
Complete below
003-886 011119 (BRC25)
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
38 Investment Growth Bond
INVESTMENT GROWTH BOND APPLICATION FORM
SECTION 6 - INVESTMENT OPTIONS (FUNDS)
Minimum is $200 per option. The minimum initial investment is $1,000. Cash deposits will not be accepted.
Investment option Amount %
NC – Cash (3NCS) $
NC – Global Fixed Interest (3NFI) $
NC – Conservative (3NCO) $
NC – Diversified (3NDI) $
NC – Managed (3NBA) $
NC – Growth (3NGR) $
NC – Global Property (3NPR) $
NC – Australian Shares (3NAU) $
NC – International Shares (3NIN) $
Total $ 100%
Cheque (Please attach with this form, made payable to ‘CMLA - Investment Growth Bond’)
Direct credit (Instructions below)
1.
De
posit the investment using recipient reference ‘IGB <insert your account name>’ into the following bank account:
Account name: CMLA No 1 account, BS
B: 062 000, Account number: 1085 2246
2.
Re
quest a receipt for the deposit.
3.
Ma
il the original Application documents with a copy of the deposit receipt.
Please note we do not direct debit funds from a client’s bank account.
Please indicate () how will you be paying
SECTION 7 - AUTOMATIC WITHDRAWAL FACILITY DETAILS
or
Complete this section if you will be investing at least $10,000 and you wish to arrange for regular payments from your investment.
%
of the value of units at each date (if less
than $500, no amount will be withdrawn)
$
Amount of each payment (minimum $500)
First withdrawal date
Last withdrawal date (if required)
Frequency
Monthly Quarterly YearlyHalf-yearly
Please complete the banking details to enable funds to be
deposited into an account.
Note: we will not pay automatic regular withdrawals by cheque.
Na
me of financial institution
BSB (Branch number) Account number
Account name (must be in the name of the Bond Owner(s))
$
Initial investment amount
Please tick () to confirm any additional amounts received should be invested as per current investment option
Adviser use only
1.
At
tach a copy of the deposit receipt and fax all documents to CommInsure Administration on 1300 852 094. No cover
sheet is required OR
2.
Sc
an all documents and attach the file to an email addressed to NewBusinessIGB@cba.com.au. The subject line
should read ‘New application for <insert clients name>.
3.
Re
tain the original Application documents in your client file.
BPAY
®
(Important: Please refer to page 14 of the PDS before using BPAY
®
.
If this is your initial investment then we will contact
your financial adviser (or you, if you do not have a financial adviser) and provide our
BPAY
®
Biller Code and your unique
Customer Reference Number (CRN). The maximum
BPAY
®
amount is $100,000.
® Registered to BPAY
®
Pty Ltd ABN 69 079 137 518
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
003-886 011119 (BRC25)
39Investment Growth Bond
SECTION 8 - ADVISER SERVICE FEE(S)
Complete this section if you consent for CMLA to pay your financial adviser(s) a one-off and/or an ongoing Adviser Service Fee.
One-off Adviser Service Fee
I/We consent for CMLA to deduct a one-off Adviser Service Fee of
$
(please specify the total dollar amount)
on
(insert date)*. Any payments to financial advisers are in accordance with the arrangements we have with
their dealer group. My financial adviser(s) and allocations are noted below.
Name of financial adviser Allocation of dollar or percentage amount**
1.
2.
*
If this date is prior to the commencement of the policy, we will deduct the one-of
f Adviser Service Fee one day after the
commencement date.
** Only required if the payment is to be split between two financial advisers.
The amount nominated above should be deducted from my chosen investment options as follows:
Investment option One-off Adviser Service Fee
NC – Cash (3NCS) $
NC – Global Fixed Interest (3NFI) $
NC – Conservative (3NCO) $
NC – Diversified (3NDI) $
NC – Managed (3NBA) $
NC – Growth (3NGR) $
NC – Global Property (3NPR) $
NC – Australian Shares (3NAU) $
NC – International Shares (3NIN) $
Please note: where you do not indicate which investment option(s) the one-off Adviser Service Fee is to be paid from, the amount will
be deducted on a pro-rata basis.
Ongoing Adviser Service Fee
I/We consent for CMLA to deduct an ongoing Adviser Service Fee of
$
each month or
%
each year. Any payments to financial advisers are in accordance with the arrangements we have with their dealer group. My financial
adviser(s) and allocations are noted below.
Name of financial adviser Allocation of dollar or percentage amount**
1.
2.
**Only required if the payment is to be split between two financial advisers.
Allocation of ongoing Adviser Service Fee to be deducted from each Investment option
Please Note: if no nomination is made the ongoing Adviser Service Fee will be deducted on a pro-rata basis.
Investment option Fixed amount to be paid each month ($) or Allocation of percentage
NC – Cash (3NCS) $ %
NC – Global Fixed Interest (3NFI) $ %
NC – Conservative (3NCO) $ %
NC – Diversified (3NDI) $ %
NC – Managed (3NBA) $ %
NC – Growth (3NGR) $ %
NC – Global Property (3NPR) $ %
NC – Australian Shares (3NAU) $ %
NC – International Shares (3NIN) $ %
Total ongoing Adviser Service Fee $ 100%
003-886 011119 (BRC25)
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
40 Investment Growth Bond
INVESTMENT GROWTH BOND APPLICATION FORM
Part 1 – Acceptable primary ID documents
Please Select
Part 2 – Acceptable secondary ID documents
Select ONE valid option from this section only
Australian State/Territory driver’s licence containing a photograph of the person
Australian passport (a passport that has expired within the preceding two years is acceptable)
A card issued under a State or Territory law containing your Photograph and proof of age
Foreign passport or similar travel document containing a Photograph and the signature of the person
Complete this section if you do not own a document from Part 1
Select one valid option from this section
Australian birth certificate
Australian citizenship certificate
Pension or Health care card issued by Department of Human Services (previously known as Centrelink)
And one valid option from this section
(this document must contain both your full name and residential address)
A document issued by the Commonwealth or a State or Territory within the preceding 12 months that
records the provision of financial benefits to you (e.g. pension statement)
A document issued by the Australian Taxation Office within the preceding 12 months that records a debt
payable by you to the Commonwealth or a refund by the Commonwealth to you (e.g. notice of assessment)
A document issued by a local government body or utilities provider within the preceding three months
which records the provision of services to you (e.g. electricity bill)
If you are under the age of 18, a notice that was issued to you by a school principal within the preceding
three months and records the period of time that you attended that school
List of persons who can certify documents:
A person who is enrolled on the roll of the Supreme Court of
a State or Territory, or the High Court of Australia, as a legal
practitioner
A judge of a court
A magistrate
A chief executive officer of a Commonwealth court
A registrar or deputy registrar of a court
A Justice of the Peace
A notary public (for the purposes of the Statutory Declaration
Regulations 1993)
A notary public in a foreign country
A police officer
(Postal Agent) An agent of the Australian Postal Corporation who
is in charge of an office supplying postal services to the public
(Post Office) A permanent employee of The Australian Postal
Corporation with two (2) or more years of continuous service who
is employed in an office supplying postal services to the public
An Australian consular officer or an Australian diplomatic officer
(within the meaning of the Consular Fees Act 1955)
An officer with two (2) or more years of service with one or more
financial institutions (for the purposes of the Statutory Declaration
Regulations 1993)
A finance company officer with two (2) or more continuous years
of service with one or more financial companies (for the purposes
of the Statutory Declarations Regulations 1993)
An officer with, or authorised representative of, a holder of an
Australian financial services licence, having two (2) or more
continuous years of service with one or more licensees
A member of the Institute of Chartered Accountants in Australia,
CPA Australia or the National Institute of Accountants with two (2)
or more years of continuous membership
Documents written in a language that is not English must be accompanied by an English translation prepared by an accredited translator.
Documents in a previous name must be accompanied by a change of name certificate (e.g. marriage certificate).
Bond owner 1
Part 3 – Acceptable foreign ID documents
Complete this section if you do not own a document from Part 1
Select either
National ID card issued by a foreign government containing a photograph and signature of the
person in whose name the document is issued
Or select two valid options from this section
Foreign driver’s licence that contains your photograph and date of birth
Foreign citizenship certificate
Foreign government issued birth certificate
Bond owner 2
(Joint Owner)
SECTION 9 - IDENTIFICATION AND VERIFICATION FOR INDIVIDUALS AND SOLE TRADERS ONLY
You are required to complete this section and attach your certified ID documents and, if applicable, certified ID documents of your
Power of Attorney. The certifier must confirm that the photocopy is a true and correct copy of the original ID, followed by their
signature, name, qualification and date.
If your financial adviser (if applicable) meets the criteria below to certify your ID documents, your financial adviser must complete
section 10 of this Application Form.
Complete Part 1 (or if the individual does not own a document from Part 1, then complete either Part 2 or Part 3).
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
003-886 011119 (BRC25)
41Investment Growth Bond
SECTION 10 - FINANCIAL ADVISER USE ONLY
Verify the individual’s full name and date of birth OR residential address.
Receipt of a completed form will constitute your agreement as a reporting entity that you have completed the identification and
verification of the investor for the purposes of Anti-Money Laundering and Counter-Terrorism Financing laws.
Bond Owner 1
ID document details Document 1 Document 2
Document type (eg Passport)
Verified from
Original Certified copy Original Certified copy
Document issuer
Issue date
Expiry date
Document number
Accredited English translation
N/A Sighted N/A Sighted
Bond Owner 2
ID document details Document 1 Document 2
Document type (eg Passport)
Verified from
Original Certified copy Original Certified copy
Document issuer
Issue date
Expiry date
Document number
Accredited English translation
N/A Sighted N/A Sighted
Lodging an Application for a CommInsure Investment Growth Bond via eProcess (fax or email) (adviser use only)
Please read the terms and conditions below carefully before following the eProcess instructions outlined.
eProcess instructions (adviser use only):
1.
Complete all relevant sections of the Application form in the PDS, dated 1 November 2019.
2.
Gather all required documentation, including the completed Application Form, identification and verification schedule, and any
other documentation requested. Refer to the checklist on page 34 of the PDS.
3. Fax all documents to CommInsure Administration on 1300 852 094. No cover sheet is required OR
4. Scan all documents and attach the file to an email addressed to NewBusinessIGB@cba.com.au. The subject line should read
“New application for <insert clients name>.”
5.
Retain the original Application documents in your client file.
Depositing the initial investment via direct credit
When investing the initial investment can be directly deposited into CommInsure Investment Growth Bond bank account instead of
posting a cheque.
Instructions:
1.
Deposit the investment using recipient reference ‘IGB <insert your account name>’into the following bank account:
Account name: CMLA No 1 account, BSB: 062 000, Account number: 1085 2246
2.
Request a receipt for the deposit.
3.
Attach a copy of the deposit receipt to the Application.
*Please note we do not direct debit funds from a client’s bank account.
eProcess terms and conditions (adviser use only):
By using the eProcess, I (the Advisers named in Section 10 of this Application) agree to the following additional terms and conditions:
1. Originals of all documents sent via the eProcess must be retained by me and be made available to CMLA upon request.
2.
Documents sent to the nominated fax number are said to be received by CMLA on the date that they have a record of having
received the documents. However, if the fax is received after 5 pm on a Sydney business day, the fax will not be regarded as
being received until the next Sydney business day. I also understand that where CMLA has no record of receiving a document,
this may mean that I will have to recommence the application process and a new quote may be required.
3.
Documents sent to the nominated email address are said to be received by CMLA on the date we have a record of sending an
acknowledgement back to you that the application has been received. If your original email is received after 5 pm on a Sydney
business day, then we will not view the email until the next Sydney business day.
The following requirements apply to deposits into the CommInsure Investment Growth Bond bank account
4.
If you have banked the full amount in relation to any application into the bank account nominated by CommInsure, you must
attach a copy of the deposit receipt.
5. You must bank the full amount in relation to any application into the nominated bank account. Partial payments will mean that
the application process will not be able to commence until we have reconciled such payments.
6. If a payment is made into any bank account other than the one nominated by CommInsure above, CommInsure will not be
accountable for any financial losses incurred.
003-886 011119 (BRC25)
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
42 Investment Growth Bond
INVESTMENT GROWTH BOND APPLICATION FORM
SECTION 10 - FINANCIAL ADVISER USE ONLY
Customer Contact
No Yes
If required, do you give us permission to contact the Bond Owner(s) direct to clarify any necessary matter?
I certify that I have provided the Bond Owner(s) with the Investment Growth Bond PDS with a date of 1 November 2019.
I certify that the adviser sections of the relevant Identification and Verification form for all Bond Owner(s) have been completed.
Where any Adviser Service Fee(s) have been noted in Section 8, I certify that I am able to set up this Adviser Service Fee
arrangement with the Bond Owner(s) and that they have agreed to this arrangement and that I have read and understood page 27
of the PDS (Adviser Service Fees).
Financial adviser declaration
Signature of financial adviser 1
Date
/ /
Signature of financial adviser 2
Date
Date Verified
/ /
Identification and verification conducted by
Name of financial adviser 1
Name of financial adviser 2
Financial adviser’s number
Financial adviser’s number
AFS Licensee name
AFS Licensee name
Phone number
Phone number
AFS Licence number
AFS Licence number
Before you enter into or become insured under a contract of life insurance with an insurer, you have a duty under the Insurance
Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, that is relevant to
the insurer’s decision whether to accept the risk of insurance, and if so, on what terms.
You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of life insurance.
Your duty, however, does not require disclosure of a matter:
that diminishes the risk to be undertaken by the insurer
that is common knowledge
that your insurer knows or, in the ordinary course of its business, ought to know, or
as to which compliance with your duty is waived by the insurer.
Non disclosure
If you fail to comply with your Duty of Disclosure and the insurer would not have covered you on any terms if the failure had not
occurred, the insurer may void your cover within three years of issuing it. If your non-disclosure is fraudulent, the insurer may void your
cover at any time.
As insurer who has not voided your cover within three years of issuing it may elect to reduce the sum that you have been insured for in
accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters
to the insurer.
SECTION 11 - DUTY OF DISCLOSURE
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
003-886 011119 (BRC25)
43Investment Growth Bond
Mail this application to:
Investment Growth Bond – New Business
PO Box 320, Silverwater NSW 2128
I/We wish to apply to The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA) for the life insurance
policy detailed in this Application.
I/We have read and understood:
The Investment Growth Bond PDS. My/Our decision to apply for this policy is based on the material received and my/our understanding of
the information included in the PDS
My/Our ‘Duty of Disclosure’ in Section 11 of this Application. I am/we are aware of the consequences of non-disclosure. I/We understand that
my/our duty to disclose continues after I/we have completed this Application until CMLA has accepted the Application for insurance in writing.
I/We declare that:
The answers to all questions, declarations and all information supplied by me or on my behalf in relation to this application is true and
correct (including those not in my/our own handwriting)
All information supplied by me or on my behalf in relation to this application is true and correct
I will promptly advise CMLA if it changes
Where the applicant is an individual, I certify that I am the named person or am authorised to provide this information on their behalf
Where the applicant is an entity, I am authorised by, and have the consent of, the entity & any Beneficial Owners* to provide the information
The entity and any Beneficial Owners are aware that information about them and the account may be provided to the tax authorities
All the information/documentation required under the Anti-Money Laundering and Counter-Terrorism Financing laws has been completed
The answers given, together with any special conditions, will form the basis of the contract
No information has been withheld which may affect CMLAs decision to provide insurance.
I/We understand that:
The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (‘CMLA’) is a wholly owned subsidiary of the
Commonwealth Bank of Australia ABN 48 123 123 124.
Neither the AIA Group nor the Commonwealth Bank of Australia Group (excluding CMLA) nor their subsidiaries, guarantee the performance
of the Investment Growth Bond or the repayment of capital or interest by CMLA. Investments in the Investment Growth Bond are not
deposits or other liabilities of the AIA Group nor the Commonwealth Bank of Australia Group (excluding CMLA) nor their subsidiaries.
Investment products are subject to investment risk which may result in loss of income and principal invested. CMLA as product issuer does
not guarantee the performance of the Investment Growth Bond except as expressly stated in the PDS.
I have read and understood the section ‘Privacy of your personal information’ on page 31 of the PDS. I acknowledge and consent to
the use and disclosure of my personal information as detailed in that section.
I declare that if this Application is signed under a Power of Attorney, the Attorney declares that they have not received revocation of
that power (Note: a certified copy of the Power of Attorney should be submitted with the Application. This must be accompanied
by information/documentation required under Anti-Money Laundering and Counter-Terrorism Financing laws for both the Power of
Attorney and the Bond Owner(s)).
The policy will not commence until CMLA accepts this application in writing, receives the first contribution and issues a Policy Document.
I/We have read page 27 of the PDS concerning the Adviser Service Fee and consent for CMLA to deduct the Adviser Service Fee as
indicated in this Application Form.
By ticking () the box beside my signature below I indicate that I do not want to receive marketing information from CMLA.
SECTION 12 - DECLARATION
Position in company (if Bond Owner 1 is a company) Position in company (if Bond Owner 2 is a company)
If the Applicant is a company then this must be signed by an authorised officer (e.g. Director, Company Secretary).
* The definition of Beneficial Owner can vary depending on the nature of the entity structure. Please refer to the appropriate Anti-Money Laundering and Counter-
Terrorism Financing forms, for specific definitions. These forms can be downloaded from commbank.com.au/igb or contact 1800 624 100 to request a copy.
Signature of Bond Owner 1
Date
/ / / /
Signature of Bond Owner 2
Date
Signature of Life Insured 1
Date
Signature of Life Insured 2
Date
/ / / /
003-886 011119 (BRC25)
Issued by The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA).
‘CommInsure’ is used under licence by CMLA.
44 Investment Growth Bond
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