1266.0 IND JOIN 09/21 ISS14 page 8 of 8
7. 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.
• Any hospital, doctor or other person who has treated or
examined me to give to the Insurer any information on my
illness or injury, medical history, consultation, prescription
or treatment or copies of all hospital or medical reports.
I declare that:
• My answers and declarations on this form are true and
correct (including those not in my own handwriting).
• I’ve read and understood the Product Disclosure
Statement that came with this form and the Insurance
in your super guide for my division at australiansuper.
com/InsuranceGuide and understand that the additional
information referred to in the guide is also part of the
Product Disclosure Statement.
• As part of my AustralianSuper membership, I agree to
abide by and be bound by the Trust Deed and Rules at
australiansuper.com/TrustDeed
• 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 Manage
my communications section of my online account..
A summary of AustralianSuper’s Privacy Collection
Statement is at the front of this booklet. 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
For information on the Insurer’s privacy and information-
handling practices, read their Privacy Policy Statement at
www.tal.com.au or call 1300 209 088 for a copy.
I acknowledge that:
• If I haven’t completed section 4 of this form, there’ll be no
change to any basic insurance cover I have or am eligible for.
• The answers I’ve provided will form the basis of the contract
of insurance, and that cover will 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.
• 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 fix any of my cover, I understand that my cover amount
won’t change (except fixed TPD cover reduces gradually
from age 61 to zero at age 65) but the cost will increase
with age.
• 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 detailed 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.
• My eligibility to claim for benefits will be determined by the
Insurer in line with AustralianSuper’s insurance policy terms
and conditions.
• 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.
Sign here:
Date
D
D
M
M
Y
Y
Y
Y
Print full name
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