Continuation of cover application form

Continuation of cover
Application form
This form is for the continuation of insurance cover following a benefit redemption from a
'previous policy'
(insert the name of your policy/plan)
to a 'replacement policy' (select one only, as appropriate):
Zurich Protection Plus
Zurich Income Protector/Plus
Zurich Income Replacement
Zurich Superannuation Term Life Plus
Zurich Superannuation Income Protector/Plus
Zurich Superannuation Income Replacement
Before completing or signing this Application Form, please read the Zurich Wealth Protection Product Disclosure Statement (PDS) for your policy. The
PDS must be provided to you with this Application Form. It will help you to understand the products and decide if they are appropriate to your needs.
Your duty of disclosure
Before you enter into a life insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know,
may affect our decision to insure you and on what terms.
You have this duty until we agree to insure you.
You have the same duty before you extend, vary or reinstate the contract.
You do not need to tell us anything that:
• reduces the risk we insure you for; or
• is common knowledge; or
• we know or should know as an insurer; or
• we waive your duty to tell us about.
If the insurance is for the life of another person and that person does not tell us everything he or she should have, this may be treated as a
failure by you to tell us something that you must tell us.
If you do not tell us something
In exercising the following rights, we may consider whether different types of cover can constitute separate contracts of life insurance. If they
do, we may apply the following rights separately to each type of cover.
If you do not tell us anything you are required to, and we would not have insured you if you had told us, we may avoid the contract within
3 years of entering into it.
If we choose not to avoid the contract, we may, at any time, reduce the amount you have been insured for. This would be worked out using
a formula that takes into account the premium that would have been payable if you had told us everything you should have. However, if the
contract has a surrender value, or provides cover on death, we may only exercise this right within 3 years of entering into the contract.
If we choose not to avoid the contract or reduce the amount you have been insured for, we may, at any time vary the contract in a way that
places us in the same position we would have been in if you had told us everything you should have. However, this right does not apply if
the contract has a surrender value or provides cover on death.
If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.
1
Who is applying to be insured under this replacement policy?
Mr
Mrs
Miss
Ms
Other
Last name
Male
Female
Given names
Date of birth
/
/
ZU20227- V3 12/15 - MMEA-010953-2015
Residential address State
Postcode
State
Postcode
Country of residency
Postal address
Work phone number (
Fax (
)
)
Home phone number (
)
Mobile number
Email
Zurich Australia Limited ABN 92 000 010 195, AFSLN 232510
Zurich Australian Superannuation Pty Limited ABN 78 000 880 553, AFSLN 232500
5 Blue Street North Sydney NSW 2060
Continuation of cover form – Page 1 of 8
2
What was your previous policy number?
The levels of cover and options selected on the previous policy will be transferred to the replacement policy.
3
Policy ownership details
Usually the life insured is also the policy owner. However, the life insured and the policy owner can be different.
Two people can be joint policy owners.
If you are applying for Zurich Superannuation Term Life Plus, Zurich Superannuation Income Protector/Plus or Zurich Superannuation Income
Replacement, the policy owner is the Trustee of the Zurich Master Superannuation Fund.
Who is the policy owner?
the life insured only
the Trustee of the Zurich Master Superannuation Fund
other – provide details below
Policy owner 1 (if other than life insured)
You can nominate a person, company, trustee or business partner. All nominated policy owners must sign the declaration on page 7.
Nominate a person
Mr
Mrs
Miss
Ms
Other
Last name
Date of birth
/
Given names
/
OR nominate a company / trustee / business partner
Company name and ABN / trustee(s) / business partners
Provide contact details for the nominated policy owner
Postal address
State
Postcode
Country of residence
Work phone number (
Fax (
)
)
Home phone number (
)
Mobile number
Email
Relationship to the insured
Your % interest in business (if any)
Is the policy owner the Trustee of a Self-Managed Super Fund?
No
Yes – provide details below
Trustee/s name/s (and ABN if trustee is company)
Fund name and ABN
Postal address
State
Postcode
Go to section 4
If there is an additional policy owner, continue section 3 on the next page. If there is only one policy owner, go to section 4.
Continuation of cover form – Page 2 of 8
3
Policy ownership details (continued)
Policy owner 2
Provide details of the person
Mr
Mrs
Miss
Ms
Other
Last name
Date of birth
/
Given names
/
OR provide details of company / trustee / business partner
Company name and ABN / trustee(s) / business partners
Postal address
State
Postcode
Country of residency
Work phone number (
Fax (
)
)
Home phone number (
)
Mobile number
Email
Relationship to the insured
Your % interest in business (if any)
Unless requested otherwise, where there is more than one policy owner, the party nominated as policy owner 1 will receive the correspondence
relating to the policy.
4
Beneficiary nomination (Protection Plus only)
A beneficiary nomination is optional. A beneficiary nomination can only be made if you are the sole policy owner and life insured and you
can nominate one or more beneficiaries to receive your benefits when you die.
For important information about nominating beneficiaries, refer to the PDS.
Nominate your preferred beneficiaries. Use their full name. The % of benefit column must total 100%. If you wish to nominate
your estate, please write ‘my legal personal representative’.
Name of beneficiary 1
Address
Date of birth
/
Share of benefit
/
State
Postcode
State
Postcode
State
Postcode
State
Postcode
Relationship
%
Name of beneficiary 2
Address
Date of birth
/
Share of benefit
/
Relationship
%
Name of beneficiary 3
Address
Date of birth
/
Share of benefit
/
Relationship
%
Name of beneficiary 4
Address
Date of birth
Share of benefit
/
/
Relationship
%
If you need more room to nominate beneficiaries, please attach a separate page, signed and dated by you.
Continuation of cover form – Page 3 of 8
Zurich Master Superannuation Fund
membership application
Only complete pages 4-5 if applying for Zurich Superannuation Term Life Plus, Zurich Superannuation Income Protector/Plus or
Zurich Superannuation Income Replacement.
You need to become a member of the Zurich Master Superannuation Fund to apply for Zurich Superannuation Term Life Plus, Zurich Superannuation
Income Protector/Plus or Zurich Superannuation Income Replacement. You must also complete the tax file number notification on the following page.
1
Member declaration
1.01 Please read the following information, and sign below to confirm your agreement.
I understand that, in accordance with the conditions of the Trust Deed and Rules of the Zurich Master Superannuation Fund (Fund) and
relevant superannuation legislation
• Zurich Australian Superannuation Pty Limited is the Trustee of the Zurich Master Superannuation Fund (ABN 33 632 838 393)
• the Trustee owns any policy taken out on my life
• I cannot use the Fund as collateral security, that is, for borrowing purposes
• benefits provided through the Fund are fully preserved until I have retired and attained my preservation age, or in circumstances allowed
by superannuation legislation or the Australian Prudential Regulation Authority, as detailed in the Zurich PDS for my policy
• I can only make contributions to the Fund in accordance with the relevant legislation, as detailed in the Zurich PDS for my policy, and
• I apply to Zurich Australian Superannuation Pty Limited, the Trustee of the Fund, for membership of the Fund as set out in this
Application Form. Upon my application being accepted I agree to comply with the rules governing the Fund.
I also certify that:
• I am eligible for membership of the Fund in accordance with the relevant legislation
• My decision to apply for membership of the Fund is based on the information in the PDS and my understanding of this information
• I will notify the Trustee in writing if I cease to be eligible for membership of the Fund
• I understand that my participation in the Fund will only commence after I have been advised in writing by the Trustee that my application
has been accepted
• I have provided my tax file number details on page 5 of this form.
I also agree that the Trustee may charge my account or bill me direct for any liability arising under the Superannuation Contributions Tax
(Assessment and Collection) Act 1997, and in relation to any other Government charges or imposts which relate to me.
Applicant's signature
7
Date
/
/
1.02 What type of contributions will be made?
Even if you intend to pay by rollover, please make a selection below to advise the source of any other contributions made. You may advise of
changes to your contribution type by notice to us.
Personal
Self-employed
Spouse
Compulsory employer (Superannuation Guarantee)
Voluntary employer
Salary sacrifice
Employer's full name
Zurich Australia Limited ABN 92 000 010 195, AFSLN 232510
Zurich Australian Superannuation Pty Limited ABN 78 000 880 553, AFSLN 232500
5 Blue Street North Sydney NSW 2060
Continuation of cover form – Page 4 of 8
2
Beneficiary nomination (Zurich Superannuation Term Life Plus only)
To make a nomination that is binding on the Trustee please complete the Zurich Binding Death Nomination Form.
3
Tax file number notification to Fund trustee
You must complete the TFN details below. Failure to do so will mean that the Trustee will be unable to accept your contribution.
Important information you need to know before providing your TFN
We are required to tell you the following things before you provide your TFN to the trustee. Your TFN is confidential and you should know
the following things before you decide to provide it.
• Under the Superannuation Industry (Supervision) Act 1993, we are allowed to collect your TFN.
• If you do provide your TFN to us, we will use it only for legal purposes. This includes finding or identifying your superannuation benefits
where other information is insufficient, verifying that certain contributions may be accepted, calculating tax on any superannuation lump
sum you may be entitled to, quoting your TFN to the ATO when reporting details of contributions, and providing information to the ATO.
These purposes may change in the future.
• It is not an offence if you choose not to quote your TFN. However, if you don’t tell us your TFN, either now or later, you may not be able
to make certain types of contributions and/or pay more tax than you would otherwise have to. You may be able to reclaim this through
the income tax assessment process. It may also be more difficult to find your benefits in the future to pay you any superannuation
benefits you are entitled to, or to amalgamate or find any other benefits for you. These consequences may change in the future. We will
not record a TFN provided to us from another fund or the ATO if you tell us not to in writing.
• If you provide your TFN to us, we may provide it to the trustee of any other superannuation fund to which your benefits are transferred
in the future. We will not pass your TFN to any other Fund if you tell us in writing that you do not want us to pass it on. We may also
give it to the ATO. Otherwise we will treat it as confidential.
3.01 Fund details
Fund name
Zurich Master Superannuation Fund
Fund address
Locked Bag 994, North Sydney, NSW 2059
Fund phone number
131 551
3.02 Your details
Mr
Mrs
Miss
Ms
Other
Last name
Male
Female
Given names
Date of birth
/
/
Membership number (if known)
Your tax file number
Applicant's signature
7
Date
/
/
Continuation of cover form – Page 5 of 8
Payment authority
You must complete pages 6 and 7.
1
Who is paying for this insurance?
We will send the billing details to the person you nominate (please tick one only).
Policy owner 1 – go to 2
Policy owner 2 – go to 2
Someone else (such as a company, trust or business partner) – provide details below
Mr
Mrs
Miss
Ms
Other
Last name / company / Trustee of Superannuation Fund
Given names
Postal address Contact phone number (
2
State
Postcode
Expiry date
/
)
Select how you would like to pay
2.01 Frequency of payment
Monthly
Quarterly
Half yearly
Yearly
2.02 Method of payment
Direct Debit – go to 2.03 on this page
Cheque (Half yearly / Yearly payment) – please attach a cheque
2.03 Direct debit account details
Credit card
Visa
MasterCard
Cardholder's name
/
Card number
OR
Bank, credit union or building society
Account name
BSB number Account number
_
2.04 Direct debit declaration
I/we acknowledge that this Direct debit request is governed by the terms of the Direct debit request service agreement (see page 8 of this
Application Form). I/we have read the Direct debit request service agreement and agree with its terms and conditions. I/we request and
authorise Zurich Australia Limited ABN 92 000 010 195 (user ID 117) to arrange for funds to be debited from my/our account at the Financial
Institution identified above through the Bulk Electronic Clearing System (BECS).
Name – account holder 1 / primary cardholder
Signature – account holder 1 / primary cardholder
Date
7
/
/
/
/
Name – account holder 2 (if applicable)
Signature – account holder 2 (if applicable)
7
Zurich Australia Limited ABN 92 000 010 195, AFSLN 232510
Zurich Australian Superannuation Pty Limited ABN 78 000 880 553, AFSLN 232500
5 Blue Street North Sydney NSW 2060
Date
Continuation of cover form – Page 6 of 8
Declaration of the life insured
and policy owner/s
Declarations of the life insured:
• I wish to apply for the continuation of insurance cover following a benefit redemption from my previous policy by way of the issue of
a replacement policy
•
I acknowledge my Duty of disclosure in relation to my application for cover under the previous policy, and that Zurich’s decision to issue a
replacement policy is based on the information supplied at that time and any further information supplied by me in respect of this application.
Declarations of the policy owner and additional declarations of the life insured
I/we declare that I/we:
• have read the Product Disclosure Statement for the replacement policy and apply to Zurich Australia Limited (Zurich) and/or Zurich
Australian Superannuation Pty Limited for the insurance set out in this application
• understand that the policy applied for will become effective when this Application is approved by Zurich;
• accept that the provisions of the replacement policy may differ from the previous policy;
• confirm that, at the time of applying for cover under the previous policy, the Duty of Disclosure was complied with and all
matters were completely and accurately represented (if I/we are unsure, I/we have obtained a copy of the original application form
and have checked and confirm the details or have signed a statement providing further disclosures or corrections attached to this form);
• understand that the Duty of Disclosure applies to the new policy being applied for and that Zurich’s decision to issue the new policy is
based on the representations and confirmations made by me/us (including those in bold above);
• accept that if the life insured failed to disclose relevant information that was required to be disclosed at the time of applying for cover
provided by the previous policy or misrepresented any facts and I/we do not disclose it now, Zurich may be able to avoid the new policy
or reduce the sum insured.
• have read and understood Zurich’s Privacy Policy and agree to the collection and use of personal information about me/us in the manner
described;
• agree that if I/we make any overpayment of premium that Zurich may retain the overpayment unless it exceeds $5.00; and
• understand that any loadings or exclusions that applied to the previous policy will apply to the new policy, unless Zurich notifies me/us
otherwise.
1
Declaration
Life insured signature
Date
7
Policy Owner 1 signature
7
/
/
/
/
/
Date
7
Policy Owner 2 signature
/
Date
Important notes
If the policy owner/s:
• is/are the individual trustee/s of a self-managed super fund: this form is to be signed by all trustees or person/s authorised to
sign and enter into the contract of insurance on behalf of the trustee/s in accordance with the fund’s trust deed and rules.
•
is a company: this form is to be signed by two directors, a director and company secretary, or the sole director/company secretary.
Please make a copy of this page if more signatures are required.
Zurich Australia Limited ABN 92 000 010 195, AFSLN 232510
Zurich Australian Superannuation Pty Limited ABN 78 000 880 553, AFSLN 232500
5 Blue Street North Sydney NSW 2060
Continuation of cover form – Page 7 of 8
Direct debit request service agreement
This agreement sets out the terms and conditions on which the Account Holder has authorised Zurich to debit money from their account and
the obligations of Zurich and the Account Holder under this agreement.
The Account Holder understands and agrees that:
• Direct debiting may not be available on all accounts.
The Account Holder is responsible for ensuring the specified account can accept direct debits and there are sufficient cleared funds
available in the nominated account to permit payments under the Direct debit request on the due date for payments
• Zurich accepts no responsibility for issues arising where incorrect details have been provided. The Account Holder should check the account
details provided to Zurich are correct. If uncertain, check with your financial institution before completing the Direct debit request
• Zurich will debit the account for the sum of the amounts due at the debit date for all specified policies
• Changes to bank account details must be provided in writing, or by telephoning Zurich (or by such other means as we approve)
• Zurich will give the Account Holder at least 14 days notice in writing if there are any changes to the terms of this service agreement.
Zurich agrees that:
• When the due date for payment is not a business day, the debit will be processed on the next business day.
• The Account holder can cancel, change*, defer or suspend the Direct Debit Request on a policy by providing notice to Zurich in writing
or by telephone (or by such other means as we approve), or directly with the Account Holder’s financial institution (which is required
to act promptly on the instructions). Notification must be received by Zurich at least 14 days before the next drawing date in order to
process your instructions.
*The Account Holder’s financial institution can “change” the Direct Debit Request only to the extent of advising Zurich of new account details.
• Upon request, Zurich will forward a copy of the current terms and conditions for direct debits, to the Account Holder by post, facsimile
or other agreed method.
• Zurich will provide details of this Direct Debit, on request.
Disputes
The Account Holder should give notice of any disputed debit to Zurich. Zurich will respond within 7 working days of receiving your letter.
Alternatively, the Account Holder can take it up directly with the Account Holder’s financial institution.
Dishonoured debits
If a debit is unsuccessful, Zurich will cancel the payment in respect of the dishonoured debit. In some instances, such as where your account
has insufficient funds, Zurich may notify you and attempt a second deduction from your account within 14 days. You should ensure that
your account has sufficient funds before any second deduction. If we receive new information from you after a dishonour, Zurich will process
a one-off debit to pay the policy up to date. If two consecutive dishonours occur, Zurich may cancel the authority. Zurich may charge a
dishonour fee to the relevant policy. Currently the fee is nil. The financial institution may also charge fees relating to the dishonour to the
account, which is the Account Holder’s responsibility.
Confidential information
Zurich may disclose information about your account to its banker (in connection with a claim made against it relating to an alleged incorrect
or wrongful debit made from the account), your financial institution, your adviser and to other companies within the Zurich Financial Services
Australia Group of companies. Zurich will not disclose information about you or the account to any other person, except where you have
given consent or where the disclosure is required by law.
Notices to Zurich
The Account Holder may give notice to Zurich in writing at the address shown or by contacting Zurich on 131 551.
Save File
Print Form
Zurich Australia Limited ABN 92 000 010 195, AFSLN 232510
Zurich Australian Superannuation Pty Limited ABN 78 000 880 553, AFSLN 232500
5 Blue Street North Sydney NSW 2060
Continuation of cover form – Page 8 of 8