Application for Life Insurance

Family name

DAY MONTH YEAR Female

Male Smoker Non-smoker Height Weight Post Code Post Code

Please provide details of other policy owner (if applicable)

Title Family _{name name(s)}Given

Relationship to the insured cm kg Given name(s) Title Date of birth Home address Postal address (if different to above)

Is the person to be insured a policy owner? . . . Yes No

Are you replacing an existing insurance cover within the next 6 months, or are you replacing an insurance cover you

have cancelled within the past 6 months, with the insurance cover you are applying for? . . .

If yes, please complete the Advice on Replacement Business form on page 11 (Adviser must complete page 13).

InteRnAl use Home and work phone (0 ) (0 ) (0 ) Date of birth

DAY MONTH YEAR

Mobile Email Occupation and Industry

Yes No Is CPI Increase to apply? (please note that ‘Yes’ will apply if left blank) . . .

If so, to what policy?

SmartLife _{SmartBusiness (Lump Sum only)}

Yes No Is own/any TPD being applied for? . . .

If yes, please complete section D on page 5

Are children being applied for under Kids SmartLiving? . . .

If so, please complete the separate form “Application for Kids smartliving”.

Yes No Yes No

Is this an increase to an existing policy

or a transfer from another Asteron policy? . . . Increase Transfer

If yes, please provide policy number

Convenient times

If we need to get more information from you, may one of our underwriters phone you? . . . Yes No

(this can save time and ensure that the underwriter fully understands your circumstances)

If ‘yes’, when is the most convenient time during business hours?

At home At work Days From: To:

Please choose your payment option If paying by a frequency greater than monthly, please pay the first instalment by cheque or credit card. Please enter your preferred start date

Direct debit* Credit card**

Cheque

Yearly Half-yearly Quarterly Monthly Fortnightly

N/A N/A

Please note that the first direct debit or first credit card payment will begin on date of policy issue. We will phone your adviser to confirm.

* Please fill out the direct debit authority on page 9. ** Please fill out the credit card authority on page 9. / /

Details of person to be insured and policy owner

You and the person to be insured are required to advise Asteron of any change in circumstances that is material to this application until your application has been accepted and you have received a policy document. This duty also applies when you extend, vary or reinstate your policy. It is your responsibility to ensure that you answer all of the questions fully and truthfully, and disclose any matters that could be relevant to this application, even if you have discussed them with your Adviser. If you or the person to be insured fail to provide any information that is material to this application, or if any information provided is substantially incorrect and material, then Asteron may be unable to accept this application; and any policy issued may be avoided from inception or any one or more of the benefits may be avoided from inception or reduced; and premiums forfeited; and benefits paid may have to be refunded.

Your duty of disclosure

Application for Life Insurance

PleAse AttAch GAlAxY IllustRAtIon(s) to fRont PAGe

This application form can be used for the following: (Maximum cover including existing cover in place)

Life cover Maximum $1,000,000 Trauma cover Maximum $500,000 TPD Maximum $500,000

2 3

5) a. Name of your usual doctor/medical centre

Email Phone Fax (0 ) (0 ) Address Post Code

Health and Lifestyle questions

a. Heart attack, angina, chest pain, elevated cholesterol,

stroke or any heart or vascular condition Yes No e.g. rheumatic fever? . . . b. Asthma, bronchitis, emphysema or any lung Yes No

or respiratory condition? . . . c. Depression, anxiety, panic attacks, stress (i.e. requiring

advice from a medical professional, or time off work);

psychosis, bipolar, schizophrenia, or any other mental Yes No illness, psychiatric disorder or nervous disorder? . . . .

d. Epilepsy, fainting attacks, fits of any kind Yes No or any neurological condition? . . .

e. Recurrent indigestion, ulcer, Hepatitis (A, B, C or D) or any disease or disorder of the bowel or

gastrointestinal tract, genitourinary tract or the Yes No reproductive system? . . .

f. Cancer, tumour or growth of any kind or breast Yes No lumps (even if you haven’t seen a doctor)? . . . g. Any impairment of sight or hearing or any sensory

organ, including symptoms such as tinnitus

or blurred vision? (This does not include long Yes No or short sightedness corrected by glasses) . . .

h. Back or neck pain or strain, sciatica or any other disorder

of the spine or neck or any disorder of any joint, muscle, Yes No ligament, cartilage or limb or any congenital disorder? i. Arthritis, gout, fibromyalgia, tendonitis, any rheumatic

condition, tenosynovitis, OOS, RSI or any regional

pain syndrome or chronic fatigue or persistent Yes No or undue tiredness? . . . j. Diabetes or abnormal blood sugar or any disease Yes No

or disorder of the endocrine system? . . . k. Psoriasis, eczema, moles or any other disorder of the Yes No

skin, or any allergic or chemical sensitivity reaction? . . l. During the last 5 years have you taken or are you

now taking medication of any kind, or have you undergone or intend on undergoing any medical investigation, or have you suffered from any other

health problem or physical impairment Yes No not mentioned above? . . . m. Have you ever had an application on your life deferred,

postponed, accepted with a higher than normal Yes No premium or modified from that which you applied? . . . 1) Please tick ‘yes’ or ‘no’ if you have ever experienced or suffered from, or had treatment or investigations or symptoms relating to,

any of the following conditions, symptoms, events or statements (whether diagnosed or not):

2) Have you ever smoked tobacco or any other substance in the last 12 months or do you drink more than 5 standard drinks of Yes No

alcohol per day on average? . . .

If ‘yes’ what type (e.g. cigarettes, wine)? Average daily quantity?

3) Have you ever used or injected yourself with any illegal or illicit drugs (e.g. marijuana, heroin, cocaine, narcotics, barbiturates) Yes No

or any other psychoactive drugs? . . . If you answered ‘yes’ to any of these questions please provide details below (more space on page 3 and page 12):

Q No. injury or testsSickness, Start date Finish date Details of treatment of Medical Practitioner / HospitalFull name / Address

/ / Degree of recovery / / / / / / % %

Type of usage (alcohol, heroin etc)

Q No. Date from Date to

/ / / /

/ / / /

4) Have you ever received advice, counselling or treatment for the use of drugs or alcohol? . . . If you answered ‘yes’ to questions 3 or 4 please provide details in the following table (more space on page 3 and page 12):

Further comments – Please write the question number that the comment corresponds to

6) Has your mother or father or any brother or sister had breast, ovarian, colon or other cancer, diabetes, high blood pressure, heart problems,

stroke, mental disorder, haemochromatosis, Huntington’s disease, muscular dystrophy, Familial Adenomatous Polyposis, polycystic kidney or any other hereditary disease or disorder? If ‘yes’, please provide details in the following table . . . . Yes No b. How long have you been a patient of this doctor? yrs

Family member

(relationship to you) (for cancer/heart disease, specify type)Condition/Sickness Age at onset (approx) Current age or Age at death Date of last consultation / / / / Reason/ outcome of last consultation 7) AIDS declaration

I have not been infected with the virus which is believed to cause AIDS (the human immunodeficiency virus), and I am not carrying antibodies of that virus. In connection with AIDS or AIDS-related conditions, I have not sought, and I am not intending to seek a medical consultation treatment or investigation. To my knowledge, all my sexual partners in the last five years would be able to make this declaration.

I declare that to the best of my knowledge and belief the above statement is true . . . True False If ‘false’ please provide full details below

8) In the last 12 months have you taken part in or do you intend to take part in any organised sport or hazardous sport

(i.e. parachuting, diving, flying, rock climbing, ocean racing, motor racing etc)? . . . Yes No

9) Females only: Are you currently pregnant? . . . Yes No Details

10) Were you born in New Zealand? (If ‘yes’ please go to question 12). . . Yes No

11) Are you a New Zealand Citizen or do you hold a New Zealand permanent resident visa? . . . Yes No

12) Do you have definite plans to travel overseas in the future for either work or personal reasons? (If ‘yes’ please provide details). . . Yes No a. If ’yes’ due date

b. Have there been or are there expected to be any complications with this or any previous pregnancies?

If ‘yes’ please provide details . . . Yes No

How long have you

lived in New Zealand? yrs

Country of birth

Visa type

4 5

What is your insurance history?

C

If you have existing life or disability insurance, we may take this existing insurance cover into account when considering this application.

1) Do you have with us or any other company, or are you currently applying for (other than this application), any type of life, Yes No superannuation, sickness, accident, trauma, lump sum disablement or disability insurance. If ‘yes‘, please provide details below.

Is this policy to be kept or

Name of company Type of insurance Insured benefit Date commenced discontinued/replaced?

If a policy is to be discontinued or replaced please complete the “Advice on Replacement Business” on page 11.

2) Has any application for insurance ever been refused, postponed, accepted with an increased premium or on modified terms? Yes No If ‘yes’, please provide details below. . . .

3) Are you claiming or have you ever claimed life or disability benefits from any source e.g. an insurance policy, ACC, social security Yes No (including unemployment benefits), sickness benefits, third party etc? If ‘yes’, please provide details below. . . .

$ $ / / / / / / / / / / / /

Has the claim been

Occupational details

D

1) Name and address of present employer or name and address of your business if self-employed

2) Do you own, have shares in, or any financial interest in any other business or entities, companies, other than your main Yes No operating entity as listed above? If ‘yes’, please provide name, your involvement and its principal function. . . . .

Yes No

3) Are you self-employed (either wholly or in part)? . . .

If ‘yes’, please tick one of the following:

Sole trader Partnership Employed by own company/trust Farmer

c. What percentage of the business do you own? . . . . d. What percentage does your trust alone own? . . . .

4) Please give details of your current and previous occupations or jobs over the last five years, including any period unemployed, travelling, studying etc. If you have a second occupation please give details in question 9.

Name Street address

a. How many people do you employ (excluding you and your spouse)? . . . Full-time

Contract %

% %

b. What percentage of work is? Freelance

Part-time

Occupation Industry Start date Finish date

/ / / / / / / / / / Present / / Par tner ship S elf-employed

Employed Employed by own compan

y/trust

%

/ /

6) How many hours do you work per week in your main occupation?

How many weeks do you work per year? 7) What are the principal duties of your occupation and where do you perform these duties?

Duties Percentage Location Percentage (eg office work, supervision, selling etc) of time (eg office, on site, at home, driving etc) of time

% % % 100 % % % % 100 % 8) Do you perform manual work either regularly or occasionally in your occupation? Yes No

If ‘yes’, please describe activities. . . .

9) Do you hold any tertiary qualifications or trade licensing certification relevant to your occupation and/or are you a member Yes No of a professional body? If ‘yes’, please provide details. . . .

Qualification Membership

6 7

Yes No

10) Do you have any other occupation(s) or do part time work? If ‘yes’, what are your duties? . . .

11) Do you intend to change your occupation, hours, or duties, employment status or take extended leave in the next 12 months? Yes No If ‘yes’, please provide details of change. . . .

12) Are you aware of any potential redundancies, restructuring, or sale of the assets or shares in the company you are Yes No employed by, whether formally notified or not? If ‘yes’, please provide details. . . .

Hours per week How long have you been

doing this second job? Annual income

from this work $

Date of

I consent to Asteron Life Limited seeking medical information from any doctor or other medical provider I have consulted, to the extent this is reasonably necessary to evaluate my Insurance application, administer any policy that arises from the application, and consider claims against and validity of that policy.

I understand that a third party may also be used to process this information request for Asteron Life Limited. I authorise any such doctor or other medical provider to provide such information to Asteron Life Limited. I agree that a photocopy of this consent is as valid as the original.

Please complete the consent above then return with this application by: • Scan and email to:

Auckland: [email protected]

Rest of New Zealand: [email protected] • Fax to 0800 246 067

• Mail to:

Auckland: Freepost Authority 795 – PO Box 204077, Highbrook Mail Centre, Auckland 2161 Wellington: Freepost Authority 795 – PO Box 30131, Te Puni Mail Centre, Lower Hutt 5040 For any assistance or help in completing this form please call us on 0800 808 101

Applicant’s personal details

My Doctor is

Title _name(s)Given

DAY MONTH YEAR Date of birth Phone Post Code Post Code Postal address Postal address Family name Name of Doctor/ Practice Authorised signature SIgn here Date / /

8 9 Parts 2, 3 and 4 apply to the Person to be Insured only.

1) I/We the person(s) applying for this insurance have read and understood the above Privacy Statement as well as the Acknowledgement, Authorisation and Declaration, Medical Authorisation, and personal statement sections. I/We agree that this application, declaration and all relevant personal statement(s) will form part of the basis of the proposed contract between me/us and Asteron. I/We understand that if I/we fail to provide any information that is material to this application, or if any information provided by me/us is substantially incorrect and material, then Asteron may not be able to accept this application; and any policy issued may be avoided from inception or any one or more of the benefits may be avoided from inception or reduced; premiums forfeited; and benefits paid may have to be refunded. I/We confirm that the information provided in this application is either in my/our own handwriting or has been checked and approved by me/us as being accurate and complete.

2) I, the person to be insured, authorise:

Asteron to obtain at any time from any employer, doctor, hospital, health agency, insurance office, Accident Compensation Corporation, Inland Revenue Department, Work and Income, Department of Justice, or any other person or entity, any and all information Asteron may require to perform or complete any of the purposes in connection with which I have provided personal information about myself or any person to be insured with Asteron. A photocopy of this authorisation shall be read as the original and any such person or entity is directed by me to release to Asteron any personal information they hold concerning me.

3) I, the person to be insured, understand that:

a. this application will form part of the basis of the proposed contract for insurance.

b. I am required to advise Asteron of any change that is material to this application up until my application has been accepted and the Policy Owner has received a policy document. This duty also applies when any application is made to extend, vary or renew that policy.

c. I understand that if I fail to provide any information that is material to this application, or if any information provided by me is substantially incorrect and material, then Asteron may be unable to accept this application; and any policy issued may be avoided from inception or any one or more of the benefits may be avoided from inception or reduced; premiums forfeited; and benefits paid may have to be refunded.

d. I will only be insured for pre-existing conditions if I have told Asteron about them in writing and insurance for those pre-existing conditions has been accepted by Asteron in writing.

e. any benefit payable under this policy may be reduced or avoided subject to the terms and conditions of the proposed contract. f. the information provided in this application is either in my own

handwriting or has been checked and approved by me as being accurate and complete.

4) I, the person to be insured, declare that:

All the answers in this application are true and complete. In addition, I have advised Asteron of any and all additional information that may affect its decision to accept the risk and the terms of insurance applied for, whether requested in the application or not and I acknowledge that it is my responsibility to ensure that I have provided all information that may affect Asteron’s decision to accept the risk and the terms of insurance applied for, whether requested in the application or not.

Asteron Life Limited (“Asteron”) and the wider Suncorp Group complies with the Privacy Act 1993 when dealing with personal information.

Collection & Use of information

We confirm that we collect and use personal information about you or any person to be insured with Asteron for the following purposes:

• To enable any application you make, or any policy you hold with Asteron or any other insurance office, to be processed, underwritten, reinsured and/or accepted.

• To enable any policy held with Asteron to be serviced and maintained, and to enable any claim you make against such a policy to be processed, including checking the validity of the policy.

• To enable Asteron and its authorised intermediaries to provide you (including by electronic means) with, or have provided to you, advice and information concerning life insurance, superannuation, income protection insurance, or any other insurance or investment products and services.

Disclosure of Information

We may disclose your personal information to third parties for the purpose of providing our services to you or in order to comply with legal requirements. We may appoint a new adviser to ensure the continuation of our services to you which could require the disclosure of personal information.

Storage, Access & Correction

Your details are stored securely with companies within the Suncorp Group and you can contact us at any time to request access to and correction of your personal information.

For further information, please refer to the “Asteron Privacy Statement” which is specific to New Zealand law and the Suncorp Group’s “Suncorp Privacy Policy”. Both are available at

www.asteron.co.nz, by phoning 0800 808 101, or by writing to Asteron Life Limited, PO Box 894, Wellington 6140.

/ /

/ / Date Signature

Person to be Insured

Other Policy Owner

SIgn here

If the Person to be Insured is also a Policy owner, that person need only sign once in the box marked ‘Person to be Insured’.

Privacy Statement

Acknowledgement, Authorisations and Declaration

F

I authorise Asteron Life Limited to charge my:

Please tick one. . . . _{Visa MasterCard}

Card holder’s signature

First payment All payments Card holder’s

name

Card number Expiry date

Date

InteRnAl use: Policy number

Authority to accept direct debits

of account (holder)

0040 05 2003

Approved Date received Recorded by Checked by Bank stamp

Customer to complete bank/branch numbers and account number and suffix of account to be debited. (If your suffix is only two numbers, insert a zero first).

Date / / Bank branch Address Town/City

0 1 0 0 4 0 9

I/We authorise you until further notice in writing to debit my/our account with all amounts which Asteron Life Limited (hereinafter referred to as the Initiator) the registered Initiator of the above Authorisation Code, may initiate by direct debit. I/We acknowledge and accept that the Bank accepts this authority only upon the conditions listed on the reverse of this form.

BANK BRANCH ACCOUNT NUMBER SUFFIX

For Bank use only

PAYER PARTICULARS PAYER CODE PAYER REFERENCE/CONTACT NUMBER

A S T e r O n

Details to appear on my/our bank statement (to be completed by Initiator)

Payer’s details

Given name(s) Family name Title Authorised signature SIgn here SIgn here

Credit card authority

Direct debit authority

/ / InteRnAl use:

client number

H

10 11

Conditions of the Authority to accept direct debit

1) The Initiator:

a. undertakes to give written confirmation to the Acceptor of the commencement date, frequency and amount of the direct debit. In the event of any subsequent change to the frequency or amount of the direct debits, the Initiator has agreed to give written advance notice at least 30 days before the change comes into effect.

b. may, upon the relationship which gave rise to this Authority being terminated, give notice to the Bank that no further direct debits are to be initiated under the Authority. Upon receipt of such notice the Bank may terminate this Authority as to future payments by notice in writing to me/us.

2) The Customer may:

a. at any time, terminate this Authority as to future payments by giving written notice of termination to the Bank and to the Initiator. b. stop payment of any direct debit to be initiated under this Authority by the Initiator by giving written notice to the Bank prior to the

direct debit being paid by the Bank.

c. where a variation to the amount agreed between the Initiator and the Customer from time to time to be direct debited has been made without notice being given in terms of clause 1(a) above, request the Bank to reverse or alter any such direct debit initiated by the Initiator by debiting the amount of the reversal or alteration of a direct debit back to the Initiator through the Initiator’s Bank; provided such request is made not more than 120 days from the date when the direct debit was debited to my/our account.

3) The Customer acknowledges that:

a. this Authority will remain in full force and effect in respect of all direct debits passed to my/our account in good faith notwithstanding my/our death, bankruptcy or other revocation of this Authority until actual notice of such event is received by the Bank.

b. in any event this Authority is subject to any arrangement now or hereafter existing between me/us and the Bank in relation to my/our account. c. any dispute as to the correctness or validity of an amount debited to my/our account shall not be the concern of the Bank except in

so far as the direct debit has not been paid in accordance with this Authority. Any other dispute lies between me/us and the Initiator. d. the Bank accepts no responsibility or liability for the accuracy of information about direct debits on Bank Statements.

e. the Bank is not responsible for, or under any liability in respect of:

• any variations between notices given by the Initiator and the amounts of direct debits;

• the Initiator’s failure to give written advance notice correctly nor for the non-receipt or late receipt of notice by me/us for any reason whatsoever. In any such situation the dispute lies between me/us and the Initiator.

f. notice given by the Initiator in terms of clause 1(a) to the debtor responsible for the payment shall be effective. Any communication necessary because the debtor responsible for payment is a person other than me/us is a matter between me/us and the debtor concerned. 4) The Bank may:

a. in its absolute discretion conclusively determine the order of priority of payment by it of any monies pursuant to this or any other. Authority, cheque or draft properly executed by me/us and given to or drawn on the Bank.

C

Details of replacement – statement of adviser/intermediary

B

Details of contract /policy/plan being replaced

Advice on Replacement Business

This form must be completed when a regular premium life or disability policy, or a regular contribution superannuation plan, is replaced by a new policy or plan. Completion of this form is optional for the replacement of a policy/plan by a single premium/contribution unbundled policy/plan.

A separate form is to be completed for each existing contract, policy or plan to be replaced. The original of this form will be returned to the Applicant, and a copy held by the Company issuing the new contract, policy or plan.

Policy

Date / /

Yes No

Is initial commission being received in relation to the new contract? . . .

Yes No

Is installment commission being taken as an alternative form? . . .

1) The specific reasons for the replacement of this existing contract/policy/plan are:

2) The policy to be replaced cannot adequately fulfil the owner’s objectives because:

Issuer Asteron Life Limited

note: Please use the “Transfer request Form” if transferring from an existing Asteron policy.

Name of Client

Type of

contract/policy/plan Annual Premium or Contribution

Name of Company

$

ASTERON LIFE LIMITED

Name of Client Name of Company

A

Details of new contract/policy/plan

Type of

12 13

E

Applicant acknowledgement

D

Advice to applicants

3) The following death or disability risks are not covered by the new contract/policy/plan which were covered by the old contract/policy/plan:

I/We acknowledge there may be advantages and disadvantages involved in replacing an existing contract, policy or plan, such as: 1) there are sometimes establishment costs in setting up a contract, policy or plan. Replacing it with a new contract, policy or plan

may involve further establishment costs;

2) if the policy which is being replaced was purchased on the life assured at a younger age, the same or similar benefits in the new policy may now cost more;

3) a change in health, pastimes or occupation of the person to be insured may affect insurability, and the new policy may contain restrictions, limitations, and/or be more costly;

4) in a new policy the Suicide Exclusion Clause may recommence;

5) conditions or benefits may be more (or less) favourable under the contract, policy or plan which is being replaced; for example, the contract duration, wordings, and/or benefit definitions may differ;

6) if the purchase of the new contract, policy or plan involves using or borrowing against cash values of any existing policy(ies) or plan(s), these monies may be beyond the applicant’s future ability or intention to repay. This may mean a loss or reduction of the benefits under the existing policy(ies) or plan(s).

I/We also acknowledge that this information was provided and explained before I/we signed the application for the new contract, policy or plan.

I am/We are aware that I/we may withdraw this application in writing within the “free look” period of a minimum of seventeen (17) days from the date the new contract, policy or plan is issued. In this event the Company will refund any premium, deposit or other payment made in respect of the proposed replacement contract, policy or plan. In the case of a single premium insurance policy, or a single contribution plan, or a contract, policy or plan which depends upon a stated rate of interest and/or a stated group of assets, the minimum “free look” period is seven (7) days.

/ / Date

Adviser’s Signature

You may find this advice helpful in deciding whether or not to replace an existing contract, policy or plan. This includes all situations where a new contract, policy or plan is being issued within a period of six (6) months after an existing contract, policy or plan has been discontinued, or six (6) months before an existing contract, policy or plan is intended to be discontinued, and:

1) the insured (or one of the insureds) is the same, or

2) the applicant (or one of the applicants) is known to be the same, or

3) the premium payer or contributor (or one of the premium payers or contributors) is known to be the same.

I confirm that the illustration attached to this application accurately reflects the Person to be Insured and the details

and requirements of the Policy Owner(s) and has been verified by the Policy Owner(s) . . . Who completed this application form (i.e. whose

handwriting)?

Signature of Adviser

1) Please tick the appropriate space below if you wish to choose a specific commission type or one of the FlexiRate options. If left blank,

Upfront commission will apply. Retention commission only applies if the Retention commission option is selected.

Date / /

Adviser’s name Adviser no.

Adviser’s daytime ph no. (0 ) Email

SmartLife

* nil commission will apply

Commission type Flexirate If left blankstandard commission applies

Nil comm* 25

50 75

Upfront Retention Level

2) Commission split If left blank your default commission split will apply.

% % %

Adviser name Adviser number commissionInitial commissionService commissionRetention Production

% % % 100 % 100 % 100 % 100 % % %

Adviser’s report

3) Multiple Life / Multiple Application Discounts If left blank no discount will apply

a. Would you like the multiple life discount to be applied to this Asteron application? . . .

If ‘yes’, please list the policy number(s) / names:

1) 2)

3) 4)

5) 6)

7) 8)

Please specify the relationship to the Life Insured :

b. Would you like the multiple application discount to be applied to this Lump Sum application? . . .. . .

If yes, please list the corresponding policy number(s):

1) Income Protection 3) SmartBusiness

4) If medical requirements are requested, how often would you like to be followed up?

Business Partner

Spouse De Facto Partner Immediate family member

Once per fortnight Once per week

2) Business Expenses 4) SmartLife

Yes No Yes No

14 15

Additional information about this application

Dianne Wells

MANAGER, INTERMEDIATED OPERATIONS Asteron Life Limited

Signature of Adviser

Thank you for choosing Asteron. We are committed to providing high quality products at competitive prices.

Please keep your Temporary Protection Certificate in a safe place until your policy document arrives.

TEMPORARY PROTECTION CERTIFICATE

Name of Person to be Insured

Subject to payment of the first premium being made at the time of this application or receipt of either a completed and authorised direct debit authority or credit card authority, the person named above will have temporary protection from Asteron Life Limited on the terms and conditions shown on the back of this certificate. Under this temporary protection, the person named above will be insured in the event of death or, if the person is disabled from any of the following conditions during the period of temporary protection, we will still cover that person on the terms that would have applied before that disablement subject to the maximums shown on the back of this certificate: Coma, paralysis, blindness, deafness, loss of speech, loss of limbs, major head trauma and severe burns.

16 16

Terms and conditions for temporary protection

1) This temporary protection expires on the earliest of the following to occur: a. the policy starts, or

b. we receive a request to cancel the application, or

c. we advise you, or the Person to be Insured, that the application has been refused, or d. 60 days have passed since this temporary protection started.

2) The amount of temporary protection will not exceed the lesser of the current protection applied for and $550,000. The maximum payable for We Pay Your Premium is $100 per month.

3) There is no protection if the Person to be Insured is under 16 years old or: a. for Life cover, the Person to be Insured is over 65 years old,

b. for trauma and total and permanent disability cover the Person to be Insured is over 60 years old, c. any details on this certificate are incorrect or incomplete,

d. the disablement is a result of any condition for which symptoms existed before the application date,

e. the disablement is a result of any condition for which medical treatment was recommended by a doctor before the application date, f. the Person to be Insured has in the past had an insurance application refused or postponed by any life insurance company, been offered a non-standard premium rate or a reduced death benefit by any life insurance company,

g. any information on the application is incomplete,

h. we believe that protection for the Person to be Insured would have been refused anyway,

i. a similar application has been accepted and a policy issued by another company since you completed this application. 4) There is no cover if death or disablement occurs as a direct or indirect result of any of the following:

a. a self-inflicted act of the Person to be Insured, whether sane or insane at the time,

b. the Person Insured is contemplating seeking medical advice in the 30 days following the date of application,

c. the illness causing the death of the Person to be Insured is the result of symptoms that already existed prior to the date of application, d. participation in a criminal activity by the Person to be Insured,

e. the Person to be Insured participating in racing (except on foot) or any sport or pastime for which he or she has received any type of reward in the previous two years,

f. the Person to be Insured travelling by air (except as a passenger in a fully licensed aircraft owned or operated by a recognised airline over an established air route),

g. the Person to be Insured being incapable of normal personal care as a result of taking drugs, alcohol or any intoxicating substance, h. the Person to be Insured taking part in any of the risks or occupations which would exclude him or her from insurance cover

for death benefits or disablement benefits.