Occupation Declaration – Insurance Member Number*Given Name(s)*Surname*Date of Birth*(DD/MM/YYYY)Email* MobilePhone* Eligibility Questions Please complete the questions below to determine if you qualify as a white collar or professional worker. If you do qualify, you will receive a higher Death & TPD insured benefit at no extra cost. a)Are you able to carry out the identifiable duties of your current and normal occupation on a full-time basis without restriction due to illness or injury (even if you are not currently working on a full-time basis)? Full-time basis is considered to be at least 30 hours per week. Yes No b)Are the duties of your occupation limited to professional, managerial, administrative, clerical, secretarial or similar 'white collar' tasks which do not involve manual work and are undertaken entirely (or at least 80%) within an office environment (excluding travel time from one office environment to another)? Yes No If 'Yes' to questions a - b, you qualify as a white collar worker.c)Are you earning in excess of $100,000 per annum? Yes No d)Do you hold tertiary qualifications and are you a member of a professional institute or registered by a government body? OR Are you a member of your organisation's executive leadership team with more than 10 years experience in your industry? Yes No If 'Yes' to all questions (a - d), you qualify as a professional worker. If you answered 'no' to all of the eligibility questions above, you will not be eligible to change your occupation rating and your existing level of insurance cover will remain unchanged.Opt-in to maintain insurance cover I wish to maintain the following types of insurance:* Select this option if you want to retain Death cover only. ^ Select this option if you have Death cover and TPD cover and you want to retain both. Important information to note • By opting-in we will maintain your insurance even if your account is less than $6,000 or inactive for 16 months or more. • By opting-in you acknowledge that you understand the effect this may have on your account balance and you do not require any further information. • Limited cover may apply. Please see your Insurance, Fees and Costs Guide for more information. • When you are at least 25 years old and you have a balance of $6,000 or more, cover will automatically commence (eligibility requirements and limitations may apply). • Insurance fees will be deducted from your account while you have cover. • If you move to another division of the Fund you will need to opt-in again. This could happen, for example, when you leave your employer. • You can change or opt-out of (i.e. cancel) your insurance cover at any time by sending us a completed Request to Change Insurance form, available at nationwidesuper.com.au/forms or by calling us on 1800 025 241. Death cover only* Death and Total and Permanent Disablement (TPD) cover^ Income Protection cover. * Select this option if you want to retain Death cover only. ^ Select this option if you have Death cover and TPD cover and you want to retain both. Important information to note • By opting-in we will maintain your insurance even if your account is less than $6,000 or inactive for 16 months or more. • By opting-in you acknowledge that you understand the effect this may have on your account balance and you do not require any further information. • Limited cover may apply. Please see your Insurance, Fees and Costs Guide for more information. • When you are at least 25 years old and you have a balance of $6,000 or more, cover will automatically commence (eligibility requirements and limitations may apply). • Insurance fees will be deducted from your account while you have cover. • If you move to another division of the Fund you will need to opt-in again. This could happen, for example, when you leave your employer. • You can change or opt-out of (i.e. cancel) your insurance cover at any time by sending us a completed Request to Change Insurance form, available at nationwidesuper.com.au/forms or by calling us on 1800 025 241. Declaration: By submitting this form I am making the following statements: I declare that the answers to the questions in this application are true and correct. I have read Nationwide Super's Product Disclosure Statement and Insurance, Fees and Costs Guide. I have read and understood the Duty of Disclosure and I have not withheld any information that may affect the insurer's decision as to whether or not to accept my application for cover. I have read the Privacy statement. I understand that Nationwide Super and it's insurer may undertake appropriate enquiry and investigation to verify the answers I have provided. I understand that the increase in my insurance cover provided per unit will not commence until this declaration has been received and accepted by Nationwide Super. Important note: Once your application is assessed, we will notify you of the outcome. Any additional insurance cover you will be provided with as a result of this occupation change will be Limited Cover for a period of at least 12 months. The Limited Cover restriction will be removed once you have been in Active Employment for 30 consecutive days following the end of the 12 month period. Please refer to the Insurance, Fees and Costs Guide for full details Δ
