Change of policy details form

Insurance with MLC
Change of policy details form
Please PRINT and COMPLETE all relevant sections. Unless otherwise stated, all changes specified on this form will be applied to the
policy(ies) where the policy number(s) have been provided below.
Policy number(s)
1. Your policy details
Please select your product (if known):
MLC Personal Protection Portfolio
MLC Life Cover Super
MLC EasyCover
MLC Simple LifeCover
Current Details
Title
Mr Mrs Miss Ms Other First name
Middle name(s)
Family name (trustee, individual, director or secretary)
Date of birth (DD/MM/YYYY)
Trust / Partnership / Company Name / Self Managed Super Fund
Postal address*
Unit number
Street number
PO Box
Street name
Suburb
StatePostcodeCountry
*If you have changed your address please write the address MLC currently has recorded on your account(s).
2. Change of details
Please provide your new name
Title
Mr
Mrs
Miss
Ms
Given name(s) (Please Print)
MLC Limited (MLC)
ABN 90 000 000 402 AFSL 230694
(Issuer of MLC Personal Protection Portfolio,
MLC EasyCover and MLC Simple LifeCover)
Other
Surname (Family name) (Please Print)
NULIS Nominees (Australia) Limited (Trustee)
ABN 80 008 515 633
AFSL 236465
(Issuer of MLC Life Cover Super)
Trustee for the MLC Super Fund
ABN 70 732 426 024
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2. Change of details (continued)
Please attach evidence of your change of name, such as an original certified copy of your marriage/divorce certificate,
license or deed poll. Please sign using your previous and new signatures to enable MLC to cross-check your request.
Note, faxed copies are not accepted.
Previous Signature
New Signature
Date (DD/MM/YY)
✗
Date (DD/MM/YY)
✗
If the Policy Owner is a company and you wish to register any changes other than change of address or contact details, please call the
MLC Client Service Centre on 132 652.
Change of address
Residential/Company address
Unit number
Street number
PO Box
Street name
Suburb
StatePostcodeCountry
As above
Postal address
Unit number
Street number
PO Box
Suburb
Street name
StatePostcodeCountry
Change of contact details
Home number
Best contact time
Day(s) am/pm
Work number
Best contact time
Day(s) am/pm
Mobile
Best contact time
Day(s) am/pm
FaxEmail
3. Tax File Number (TFN) details – MLC Life Cover Super only
Please note: premiums will not be accepted where a member fails to provide their TFN.
Tax File Number (TFN)
When collecting your TFN we are required to tell you:
• The Trustee is authorised to collect your TFN under the Superannuation Industry (Supervision) Act 1993
• It isn’t an offence to decline to notify the Trustee of your TFN
• If you don’t notify the Trustee of your TFN, they may not be able to (now or in the future) locate, amalgamate and identify your benefits
in order to pay you
• The Trustee is allowed to use your TFN for lawful purposes, in particular if paying out monies, identifying and amalgamating super
benefits for surcharge purposes and for other approved purposes, and
• Your TFN will be disclosed to the Commissioner of Taxation. Your TFN will also be passed on to another super provider if your benefits
are being transferred, unless you inform the Trustee in writing not to pass on your TFN. Your TFN won’t otherwise be disclosed to any
other person.
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4. Premium contribution type – MLC Life Cover Super only
Please specify what type of premium contributions will be made by you or on your behalf? (please tick one box only).
Personal/Spouse
Employer
5. Authorised representative
Do you wish to:
Establish a new Authorised Representative on your policy.
Replace an existing Authorised Representative on your policy.
Please complete the following section if you wish to appoint an Authorised Representative to have access to your information on
this policy.
An authorised representative cannot transact on the policy and will stay in place indefinitely until a request to change is received in
writing from you.
Title
Mr
Mrs
Miss
Ms
Other
First name
Middle name
Family name
Date of birth (DD/MM/YYYY)
Email
MLC Customer Number (if existing customer)
Residential address
Unit number
Street number
PO Box
Suburb
Street name
Postcode StateCountry
Contact details
Home telephone
Mobile phone number
Work telephone
Fax
Signature of Authorised Representative
Date (DD/MM/YY)
✗
6. Method of payment
Has there been a change to your method of payment?
No
Your current method of payment will be used
Yes
Please complete the relevant sections as applicable
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6. Method of payment (continued)
6A Direct Debit Request Schedule
Complete this section if you want to pay your premiums by automatic deduction from your nominated
financial institution account.
If you’re with one of the smaller banks or credit unions you may need to check if they can accept a direct debit request from the Bulk
Electronic Clearing System (BECS). This information should be available on your recent bank statement, on the bank’s website, or call
their customer service number.
Applicable to:
MLC Personal Protection Portfolio MLC Life Cover Super
MLC EasyCover
MLC Simple LifeCover
Surname (company/business name)
Given name(s) (or ABN)
Family name
Given name(s)
request MLC Limited (ABN 90 000 000 402) (AFSL 230694) (User ID No. 460592) to draw money from my/our account
conducted with:
Name of financial institution
Name of account holder
Address of financial institution
State
Postcode
Name of Account to be debited
BSB
Account number
Please note:
Direct debiting is not available on the full range of financial institution accounts. If in doubt, please refer to your financial institution before
completing the Schedule.
How frequently will premiums be paid?
Monthly
Half-yearly*
Yearly*
*Not available for MLC EasyCover or MLC Simple LifeCover.
Preferred draw date of the month. Please note that due to normal business processing we cannot guarantee
this date.
1st
5th
10th
15th
17th
20th
25th
I/We acknowledge that this Direct Debit Request Schedule is governed by the terms of the Direct Debit Request Service
Agreement on page 5 of this application form and the terms and conditions of the policy to which this application relates I
have read and agree to the terms and conditions.
Signature of financial institution account holder 1
Signature of financial institution account holder 2
(if applicable)
NameName
Date (DD/MM/YY)
Date (DD/MM/YY)
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6. Method of payment (continued)
6B Credit Card Deduction Authority
Complete this section if you want to pay your premiums by charging your nominated credit/debit card.
Applicable to:
MLC Personal Protection Portfolio
MLC Life Cover Super
MLC EasyCover
MLC Simple LifeCover
Name (as it appears on the card)
authorise MLC to charge my
Card type
Mastercard
Card number
Expiry date (MM/YY)
Visa
or any replacement/substituted card, for the premiums due on the policy.
Tick this box if this credit card deduction is for:
both the initial and ongoing premiums
ongoing premiums only – a cheque is attached for the initial premium
the initial premium only
If making regular payments from your credit card how frequently will your premium be paid?
Monthly
Half yearly*
Yearly*
*Not available for MLC EasyCover or MLC Simple LifeCover.
Preferred draw date of the month. Please note that due to normal business processing we cannot
guarantee this date.
1st
5th
10th
15th
20th
25th
Signature of cardholder
Date (DD/MM/YY)
6C Direct Payment of Premiums*
Complete this section if you want to pay your premiums direct to MLC by cheque or money order. Please note, this
payment method is not available for MLC EasyCover or MLC Simple LifeCover.
Applicable to:
MLC Personal Protection Portfolio
MLC Life Cover Super
I wish to pay my premium directly to MLC:
Half yearly
Yearly
MLC will send you notices for premiums prior to the due date.
If you are making your first payment by cheque for MLC Personal Protection Portfolio, make it payable to MLC Limited,
crossed ‘Not negotiable’.
If you are making your first payment by cheque for MLC Life Cover Super, make it payable to NULIS Nominees (Australia)
Limited, crossed ‘Not negotiable’.
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6. Method of payment (continued)
6D MLC Masterkey Deduction Authority
Note: Available For MLC Life Cover Super only
Complete this section if you want to pay your premiums by regular deduction from your account with an eligible MLC
MasterKey superannuation product.
Important Information
• The member must be the same for both the account with an eligible MLC MasterKey superannuation product and MLC Life Cover
Super policy.
• Only one deduction may operate on any account with an eligible MLC MasterKey superannuation product.
• It is the obligation of the member to ensure there are sufficient funds to operate the MLC MasterKey superannuation account and
pay for the MLC Life Cover Super premium. To allow completion of the MLC Life Cover Super policy, MLC requires the MLC
MasterKey superannuation account to have a minimum of 3 months premium for a monthly paid policy or the full balance of premium
for half-yearly and yearly paid policies. If the balance of the MLC MasterKey superannuation account does not meet this criteria,
another payment method should be selected (pending rollovers excluded).
Instalment deduction
• The date the deductions will commence from your account with an eligible MLC MasterKey superannuation product will depend on
when we receive this form.
• Instalments will be deducted from your account with an eligible MLC MasterKey Superannuation on:
– the same date each month for monthly payments
– the half-yearly and annual policy anniversary date for half‑yearly payments
– the annual policy anniversary date for yearly payments.
I wish to pay my premiums through a regular deduction from my MLC MasterKey superannuation product:
Monthly
Half yearly
Yearly
Declaration
I authorise the Trustee, until further notice in writing, to deduct my MLC Life Cover Super premiums from my:
new account with an eligible MLC MasterKey superannuation product; or
existing account number with an eligible MLC MasterKey superannuation product
I understand and acknowledge that:
• the Trustee may, by prior arrangement and advice to me, vary the amount and frequency of future deductions; and
• the Trustee may, in its absolute discretion, at any time by notice in writing to me, terminate this request as to future deduction.
Life Insured/Member’s Signature
Date (DD/MM/YY)
✗
7. Exceptions for changes
Changes will apply to all policies listed on this form unless indicated below.
Question(s)
does not apply to Policy number(s)
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8. Declaration
Read this section carefully before signing.
I understand and agree that:
• The details provided by me in this form are true and complete. If any sections of this form have not been completed in my handwriting,
I certify that I have checked them and the information provided is correct.
• If I have nominated or changed my Authorised Representative in respect of my policy I understand and accept the terms of that
authorisation, and my responsibilities in respect of that authorisation.
Signature of Policy Holder / Member 1*
Signature of Policy Holder / Member 2* (if applicable)
NameName
Date (DD/MM/YY)
Date (DD/MM/YY)
* FOR POLICY OWNER(S) OF MLC Personal Protection Portfolio Only
Signature of the parent or guardian is required if policy owner is under 16 years of age.
In the case where the Policy Owner is a Company;
• Two directors or a director and company secretary are to sign; or
• In the case of a sole director proprietary company only, the sole director is to sign. However, the director must indicate that he/she is
the sole director and sole secretary of the company.
Sole Director and Sole Secretary (indicate by ticking box)
9. Send us your form
Please mail your completed, signed and dated form to us at:
MLC
PO Box 200
North Sydney NSW 2059
If you have any questions, please contact your financial adviser or call us on 132 652 any business day between 8.00 am
and 6.00 pm (AEST/AEDT).
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10. Direct Debit Request Service Agreement
This Direct Debit Request Service Agreement is issued by MLC Limited, ABN 90 000 000 402 (User ID no. 460592).
This Service Agreement and the Direct Debit Request Schedule in your application contain the terms and conditions by which you
authorise MLC to draw (debit) money from your account and the obligations of MLC and you under this Agreement. You should read
through them carefully to ensure you understand these terms and conditions before signing the Schedule. Please direct all enquiries
about your direct debit to us on 132 652.
MLC’s commitment to you
MLC will give you at least 14 days notice in writing if there are changes to the terms of the drawing arrangements.
MLC will keep the details of your nominated Financial Institution account confidential, except where provided to MLC’s bank or as
required to conduct direct debits with your Financial Institution.
Where the due date is not a business day, MLC will draw from your nominated Financial Institution account on the business day before
or after the due date in accordance with the terms and conditions of your MLC policy.
MLC will not charge you for any dishonours, however:
• if your account dishonours, your Financial Institution may charge you a fee
• MLC reserves the right to cancel drawing arrangements if drawings are dishonoured by your Financial Institution.
Your commitment to MLC
It is your responsibility to:
• ensure your nominated account(s) shown in the Direct Debit Schedule are correct and that your nominated financial institution
account can accept direct debits through the Bulk Electronic Clearing System (BECS)
• ensure there are sufficient funds available in the nominated account to meet each drawing on the due date
• advise MLC if the nominated account is transferred or closed, or the account details change
• arrange an alternate payment method acceptable to MLC if MLC cancels the drawing arrangements, and
• ensure that all account holders on the nominated Financial Institution account sign the Direct Debit Request Schedule.
Your rights
Your drawing arrangements are detailed in the Direct Debit Request Schedule of your application. They are also governed by the terms
and conditions of your MLC policy. You should contact us on 132 652, providing at least 7 days notice, if you wish to alter the drawing
arrangements. You can:
• alter the Schedule
• cancel the Schedule
• stop an individual drawing
• defer a drawing
• suspend future drawings.
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