MLC Limited
ABN 90 000 000 402 AFSL 230694 MLC Nominees Pty Limited ABN 93 002 814 959 AFSL 230702 Trustee for The Universal Super Scheme ABN 44 928 361 101
MLC Insurance (Super)
Application for increases
without further medical evidence
Policy number(s)
Name of Life Insured
This form allows the Income Protection, Life Cover, Total and Permanent Disability (TPD) and/or Critical Illness benefit for a Life Insured to be increased without further medical evidence, in accordance with the terms and conditions of your policy. You should read your policy document carefully before signing this application. Your application to increase this insurance is not effective until MLC accepts this application and issues a revised schedule.
Please make sure you have attached a copy of your premium quotation to this form.
Your Duty of Disclosure
Before you enter into a contract of life insurance with MLC, you have a duty, under the Insurance Contracts Act 1984, to disclose to MLC every matter that you know, or could reasonably be expected to know, is relevant to MLC’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 MLC before such a contract of life insurance is extended, varied or reinstated. Your duty, however, does not require disclosure of a matter:
• that diminishes the risk to be undertaken by MLC • that is of common knowledge
• about which MLC knows or, in the ordinary course of business, ought to know • for which your duty of compliance is waived by MLC.
If you take out MLC Insurance (Super) the Trustee obtains life insurance from MLC on you. Because the Trustee is taking out a life policy at your request, the Trustee requires you to make full disclosure to it on the same basis.
Non-disclosure
If you fail to comply with your Duty of Disclosure and MLC would not have entered into the contract on any terms if the failure had not occurred, MLC may avoid the contract within three years of entering into it. If your non-disclosure is fraudulent, MLC may avoid the contract at any time.
Even if MLC is entitled to avoid a contract of life insurance MLC may, within three years of entering into it, elect not to avoid it but reduce the sum for which you have been insured in accordance with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to MLC.
Eligibility to apply for an increase without further medical evidence
For all increases to benefits without further medical evidence, you will need to provide proof of the event, and any additional financial evidence satisfactory to us to support the increase requested.
See your PDS for eligibility requirements.
You are not eligible to apply for an increase to your benefit without further medical evidence if you have made a claim or are entitled to make a claim under this policy.
Please PRINT and COMPLETE sections 1 and 2, which will help us to identify you, the sections which relate to the changes you wish to make and the declaration. Unless otherwise stated, all change specified on this form will be applied to the policy(ies) where the policy number(s) have been provided.
Section 1 Your policy details
Policy number(s)
Section 2 Current Policy Owner details
Title
Mr Mrs Miss Ms Other
First name
Middle name Surname
Date of birth (DD/MM/YYYY) Email address
Mobile phone number
Person whose Life is insured
Mr Mrs Miss Ms Dr Other:
First name Surname
Date of birth (DD/MM/YYYY) NAB customer number (NAB Adviser use only)
Postal Address for correspondence Address
Suburb Postcode State
Contact Details
Home telephone Best contact time Day(s)
:
am/pmWork telephone Best contact time Day(s)
:
am/pmMobile Fax
Please fill in the following sections for your application
Income Protection 4 and 7
Life Cover, TPD and Critical Illness due to a Personal event 5 and 7
Section 4 Increases to Income Protection
This insurance is being increased because the Life Insured: has married
has divorced
has completed an undergraduate degree at a Government recognised university has received an increase in their Earnings of at least 10% in the previous 12 months has a child who has started secondary school
has taken out a mortgage to purchase their home has increased a mortgage to improve their home or their spouse has given birth to or adopted a child
Income Protection Worksheet
To confirm the Life Insured’s eligibility we need you to complete this form to ensure that the maximum benefit is not exceeded.
After you increase your Income Protection monthly benefit without further medical evidence, your monthly benefit cannot exceed the lesser of (A), (B) and (C):
Your current monthly benefit (i) $
20% of your monthly benefit (ii) $ Total of (i) + (ii) = (A) $
Maximum monthly benefit across all income protection insurance
on your life held with MLC = (B) $ 30,000
Maximum insurable amount:
Your current annual Earnings (refer to the Earnings definition below)
75% of first $320,000 $
50% of next $320,001– $560,000 $
20% of next $560,001–$2,360,000 $
÷ 12 = (C) $
Earnings
If you are self employed (you directly own all or part of a business or practice), Earnings means the income of the business or practice generated by your personal efforts after the deduction of your appropriate share of business or practice expenses in generating that income.
If you are an employee (you do not directly own all or part of a business or practice), Earnings means the total remuneration paid by the employer to you, including salary, commission, fees, regular bonuses, regular overtime, fringe benefits and regular superannuation contributions paid by the employer on your behalf.
Whether you are self employed or an employee, Earnings do not include investment income, and are calculated before tax. The maximum allowable increase is the lesser of (A), (B) and (C) = (D) $
By how much would you like to increase the Income Protection benefit: $
The Policy Owner and the Life Insured make the following declarations and confirmation: I understand and agree that:
in the event of a claim, MLC may request financial documents from me to support this increase to my monthly benefit I confirm that:
Personal Event
This insurance is being increased because the Life Insured: has married
Go to
Personal events A has divorced
has completed an undergraduate degree at a Government recognised university has received an increase in their Earnings of at least 10% in the previous 12 months has a child who has started secondary school
or their spouse has given birth to or adopted a child
has taken out a mortgage to purchase their home Go to
Personal events B has increased a mortgage to improve their home
Personal events A: Birth, adoption, marriage, divorce, undergraduate degree completed,
increase in Earnings of at least 10% or child starts secondary school
Life Cover worksheet
Original Life Cover benefit $
You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following:
• 25% x original Life Cover benefit (A) $
• maximum increase (B) $ 200,000
The maximum allowable increase is the lesser of (A) and (B) $
TPD worksheet
Original TPD benefit $
You may apply to increase the TPD benefit without further medical evidence by the lesser of the following:
• 25% x original TPD benefit (A) $
• maximum increase (B) $ 200,000
The maximum allowable increase is the lesser of (A) and (B) $
Critical Illness worksheet (MLC Insurance)
Original Critical Illness benefit $
You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following: • 25% x original Critical Illness benefit (A) $
• maximum increase (B) $ 200,000
The maximum allowable increase is the lesser of (A) and (B) $
By how much would you like to increase the: Life Cover benefit $
TPD benefit $
Section 5 Increases to Life Cover, TPD and Critical Illness due to
Personal Event (continued)
Personal events B: Home loans and home improvement loans
Life Cover worksheet
Original Life Cover benefit $
You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following:
• 50% x original Life Cover benefit (A) $
• value of new mortgage (B) $
• value of latest increase to existing mortgage (C) $
• maximum increase (D) $ 200,000
The maximum allowable increase is the lesser of (A), (B), (C) and (D) $
TPD worksheet
Original TPD benefit $
You may apply to increase the TPD benefit without further medical evidence by the lesser of the following:
• 50% x original TPD benefit (A) $
• value of new mortgage (B) $
• value of latest increase to existing mortgage (C) $
• maximum increase (D) $ 200,000
The maximum allowable increase is the lesser of (A), (B), (C) and (D) $
Critical Illness worksheet (MLC Insurance)
Original Critical Illness benefit $
You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following:
• 50% x original Critical Illness benefit (A) $
• value of new mortgage (B) $
• value of latest increase to existing mortgage (C) $
• maximum increase (D) $ 200,000
The maximum allowable increase is the lesser of (A), (B), (C) and (D) $
By how much would you like to increase the: Life Cover benefit $
TPD benefit $
Business Event
This insurance is being increased because:
• the Life Insured is a key person in your business and their value to the business has
increased (outside Super only) Go to Business events A
• it forms part of a written ownership (buy/sell), share purchase, or business continuation agreement, and the Life Insured is a partner, shareholder or unit holder in the business,
and the Life Insured’s financial interest in the business has increased Go to Business events B
• the business debt the life insured is responsible for has increased Go to Business events C
Business events A: Revenue protection / key person
The value of the Life Insured as a key person is defined as the total of their remuneration package for each year excluding discretionary benefits, plus their share of net profit distributed by the business in that year.
Has the basis of measuring this remuneration been consistent over the past 3 years? Yes
No Please provide details
Life Cover worksheet (MLC Insurance only)
Original Life Cover benefit (a) $
Life Cover benefit 1 year ago (b) $
Value of key person 1 year ago (c) $
Value of key person now (d) $
Represents an increase of (d - c) / c (e) %
Value of key person 3 years ago (f) $
You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• 5 x increase, averaged over prior 3 years (ie 5 x (d - f) / 3) (iii) $
• maximum increase (iv) $ 200,000
Section 6 Increases to Life Cover, TPD and Critical Illness due to
Business Event (continued)
TPD worksheet (MLC Insurance only)
Original TPD benefit (a) $
TPD benefit 1 year ago (b) $
Value of key person 1 year ago (c) $
Value of key person now (d) $
Represents an increase of (d - c) / c (e) %
Value of key person 3 years ago (f) $
You may apply to increase the TPD benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• 5 x increase, averaged over prior 3 years (ie 5 x [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
The maximum allowable increase is the lesser of (i), (ii), (iii) and (iv) $
Critical Illness worksheet (MLC Insurance only)
Original Critical Illness benefit (a) $
Critical Illness benefit 1 year ago (b) $
Value of key person 1 year ago (c) $
Value of key person now (d) $
Represents an increase of (d - c) / c (e) %
Value of key person 3 years ago (f) $
You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• 5 x increase, averaged over prior 3 years (ie 5 x [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
The maximum allowable increase is the lesser of (i), (ii), (iii) and (iv) $
By how much would you like to increase the: Life Cover benefit $
TPD benefit $
Business Event (continued)
Business events B: Ownership protection, buy/sell, share purchase
The value of the financial interest of the Life Insured in any one year will be based on their share of the net value of the business at the end of that year (‘net’ meaning the value of the business less liabilities). The level of the Life Cover, TPD and Critical Illness benefit (as applicable) for the Life Insured must be equal to, or less than, the net value of the Life Insured’s share of the business.
What method of valuation has been used for valuing the Life Insured’s share of the business? Net Asset Backing
Capitalisation of Earnings Book Value
Other (please specify)
Has there been a change to the industry/type of business the Life Insured is engaged in? No
Yes Please advise new industry/type of business of Life Insured below.
Life Cover worksheet
Original Life Cover benefit (a) $
Life Cover benefit 1 year ago (b) $ Value of Life Insured’s share of the business 1 year ago (c) $ Value of Life Insured’s share of the business now (d) $
Represents an increase of (d - c) / c (e) %
Value of Life Insured’s share of the business 3 years ago (f) $
You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
Section 6 Increases to Life Cover, TPD and Critical Illness due to
Business Event (continued)
TPD worksheet
Original TPD benefit (a) $
TPD benefit 1 year ago (b) $ Value of Life Insured’s share of the business 1 year ago (c) $ Value of Life Insured’s share of the business now (d) $
Represents an increase of (d - c) / c (e) %
Value of Life Insured’s share of the business 3 years ago (f) $
You may apply to increase the TPD benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
The maximum allowable increase is the lesser of (i), (ii), (iii) and (iv) $
Critical Illness worksheet
Original Critical Illness benefit (a) $
Critical Illness benefit 1 year ago (b) $ Value of Life Insured’s share of the business 1 year ago (c) $ Value of Life Insured’s share of the business now (d) $
Represents an increase of (d - c) / c (e) %
Value of Life Insured’s share of the business 3 years ago (f) $
You may apply to increase the Critcal Illness benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
The maximum allowable increase is the lesser of (i), (ii), (iii) and (iv) $
By how much would you like to increase the: Life Cover benefit $
TPD benefit $
Business Event (continued)
Business events C: Asset Protection (Loan Guarantee)
The part of the Business Loan the life insured is responsible for in any one year will be calculated on their share of the Business Loan at the end of that year.
What proportion of the Business loan is the Life Insured responsible for? %
Life Cover worksheet
Original Life Cover benefit (a) $
Life Cover benefit 1 year ago (b) $ Business Loan amount the Life Insured was responsible for 1 year ago (c) $ Business Loan amount the Life Insured is responsible for now (d) $
Represents an increase of (d - c) / c (e) %
Business Loan amount the Life Insured was responsible for 3 year ago (f) $
You may apply to increase the Life Cover benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
The maximum allowable increase is the lesser of (i), (ii), (iii) and (iv) $
TPD worksheet
Original TPD benefit (a) $
TPD benefit 1 year ago (b) $
Business Loan amount the Life Insured was responsible for 1 year ago (c) $ Business Loan amount the Life Insured is responsible for now (d) $
Represents an increase of (d - c) / c (e) %
Business Loan amount the Life Insured was responsible for 3 year ago (f) $
You may apply to increase the TPD benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
Section 6 Increases to Life Cover, TPD and Critical Illness due to
Business Event (continued)
Critical Illness worksheet
Original Critical Illness benefit (a) $
Critical Illness benefit 1 year ago (b) $ Business Loan amount the Life Insured was responsible for 1 year ago (c) $ Business Loan amount the Life Insured is responsible for now (d) $
Represents an increase of (d - c) / c (e) %
Business Loan amount the Life Insured was responsible for 3 year ago (f) $
You may apply to increase the Critical Illness benefit without further medical evidence by the lesser of the following:
• (e) x (b) (i) $
• 25% x (a) (ii) $
• increase, averaged over prior 3 years (ie [d - f] / 3) (iii) $
• maximum increase (iv) $ 200,000
The maximum allowable increase is the lesser of (i), (ii), (iii) and (iv) $
By how much would you like to increase the: Life Cover benefit $
TPD benefit $
Read this section carefully before signing
I understand and agree that:
(a) I have read the Duty of Disclosure set out on page 1. I understand that, until MLC accepts this application and issues a revised
Schedule, I have a duty to disclose every matter which I know or could reasonably be expected to know is relevant to MLC’s acceptance of this application and that if I fail to comply with my duty of disclosure MLC may (as permitted by law) avoid the increase or reduce the benefits under it;
(b) The answers to the questions above are true and complete;
(c) If any answers to questions in this application are not in my own handwriting, I certify I have checked them and they are correct; (d) No increase to insurance is effective until MLC accepts this application and issues a revised Schedule;
(e) The terms and conditions of any increase in the Income Protection, Life Cover, TPD and/or Critical Illness benefit apply as
described in the relevant policy document and in any written notification of changes subsequent to the relevant policy document being issued;
(f) For Income Protection in the first 12 months after an increase under this benefit, the amount of the increase (excluding any
increases due to Inflation Proofing) covers the Life Insured for Total Disability and Partial Disability caused by an accident only;
(g) During the first six months after certain increases, the increased amounts cover you only for the following specified events caused
by an Accident:
• Life Cover: for marriage, divorce or Mortgage, the increase covers only death.
• Critical Illness: for marriage, divorce or Mortgage, the increase covers only death and critical conditions.
• TPD: whatever the reason for increase, the increase covers only TPD. The increased insurance also does not cover you for any TPD caused by sickness or injury that first happened within six months before the increase.
(h) If I have increased the Life Cover, TPD and /or Critical Illness benefit for the Life Insured in the last 13 months and that Life Insured
commits suicide MLC will only pay the Life Cover, TPD and/or Critical Illness benefit applicable before the increase;
(i) If the Life Insured has made a claim or is entitled to make a claim under this policy the Life insured is not eligible to apply for an
increase without further medical evidence;
(j) I have attached certified proof of birth, adoption, marriage, divorce, undergraduate degree, secondary school commencement,
increase in Earnings, home loan details or business event. Please see page 14 for an explanation of certified proof;
(k) If I have provided my email address for the purpose of receiving communications from MLC, I acknowledge my personal and
sensitive information may be sent to that email address. Signature of Life Insured
✗
Date (DD/MM/YYYY)Signature(s) of Policy Owner(s)
• You don’t need to complete this part if the Policy Owner is the Life Insured or if this is an MLC Insurance Super policy. • Parent or Guardian if Life Insured is under 16 years of age
• Where a company is the proposed owner of a policy there is no need for the company seal to be affixed. In the case where the Policy Owner is a company:
a) Two directors or a director and company secretary are to sign; or
b) In the case of a sole director proprietary company only, the sole director is to sign. The director must indicate that he/she is the sole director and sole secretary of the company.
Policy 1
Signature(s) of Policy Owner(s)
✗
Date (DD/MM/YYYY)✗
Date (DD/MM/YYYY)Sole director and sole secretary (indicate by ticking box)
Policy 2
Signature(s) of Policy Owner(s)
✗
Date (DD/MM/YYYY)✗
Date (DD/MM/YYYY)Proof required to increase your benefit without medical evidence
Increases as a result of birth, adoption, marriage, divorce, undergraduate degree completion or child starting secondary school
You are required to provide certified proof of the event. Certified proof is a copy of the original that is signed by one of the following people as a “true and complete copy of the original”.
• Justice of the peace • Solicitor/barrister • Police officer
• Registered medical practitioner
• Full time teacher at a school or tertiary education institution with five years service • Bank, building society or credit union officer with five years service
• Postal manager • Dentist • Pharmacist
• Minister of religion designated as an authorised marriage celebrant • Registered nurse or enrolled nurse with five years service
• Registered accountant
Increases as a result of increase in Earnings
You are required to provide proof of the increase in Earnings. This may include: • Letter from employer
• Tax returns
• Any other financial evidence we require
Increases as a result of a mortage or increase to an existing mortage You are required to provide proof of your home loan details. This may include: • Mortgage deeds or documents
• Loan certificates
Increases as a result of business events
You are required to provide proof of the business event. This may include: • Company minutes
• Ownership (buy/sell) agreements • Audited company accounts • Tax returns
This section for Financial Adviser use only
This section must be completed
Email address (contact for this application)
Financial Adviser’s instructions
(Complete details relevant to this application) Financial Adviser 1This section is to be completed by the Servicing Adviser. The Servicing Adviser will receive all correspondence for the policy.
Financial Adviser 2
Name of Financial Adviser Name of Financial Adviser
MLC Financial Adviser No. Mobile phone MLC Financial Adviser No. Mobile phone
Telephone number Telephone number
Fax number Fax number
Email address Email address
Distribution fee split
%
Distribution fee split
%
NAB Financial Planning use only:
FI/FN Number Referring BUID Number Referring Banker’s Name