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Sunday, June 25, 2017
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Application

Complete this online application if:

  • You are a member and Trustee of a Self Managed Superannuation Fund (SMSF) and wish to apply for death only or death and Total and Permanent Disablement (TPD) insurance. Note: Advisors may complete this with the express permission of the Trustee and Member, by completing the adviser Declaration at the end of the application
  • You wish to use the short form application for cover up to $750,000.
  • You wish to apply for cover greater than $750,000 and no more than $1m and you are prepared to complete the full online application, which will follow the short form application below.

OnePath is the insurer in respect of Self Secure SMSF Group Life Insurance. This application form should only be completed after reading the Self Secure SMSF Group Life Insurance Product Disclosure Statement (PDS). The PDS contains a summary of important information about the Self Secure product. The completion of this form serves as an acceptance of the terms and conditions outlined in the PDS.



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To complete this application, please choose one of the following options:

Self Managed Super Fund Details
Please enter full name of the Self Managed Super Fund
Please enter the Super Fund ABN, excluding spaces
Full name of Corporate trustee (if applicable)
Full name of First Individual Trustee
Full name of Second Individual Trustee (if applicable)
Full name of Third Individual Trustee (if applicable)
Full name of Forth Individual Trustee (if applicable)
Trustee Contact Details
Member Information
Note: You must be under age 65 to apply for death cover and under age 60 to apply for TPD cover.


White Collar - the duties of your occupation are limited to professional, administrative, clerical, secretarial or similar sedentary tasks, which do not involve manual work and are undertaken entirely (or at least 80%) within an office environment.

Non White Collar - anyone who doesn't meet the above definition of White Collar. This includes those not working and/or engaged in home duties.

I am an Australian resident or holder of a visa that allows me to work in Australia.


You must be an Australian resident or holder of a visa that allows you to work in Australia to be eligible for cover.

Medical Questionnaire
1 Are you at the date of this application off work due to injury or illness or restricted from performing any duties of your usual occupation (including homemaker duties) due to injury or illness?
2 Are you currently receiving any form of medical treatment?
3 To the best of your knowledge have you taken more than a total of seven days off work over the past 12 months due to illness or injury (other than colds or flu)?
4 Have you ever received a Total and Permanent Disability (TPD) benefit or are you eligible to claim a TPD benefit from either this fund or any other source?
5 Have you ever received medical advice, consulted a doctor, undergone medical treatment, investigations or operations for, or suffered from any of the following?
a High blood pressure, high cholesterol, heart complaint, murmur, palpitations or chest pain, stroke, diabetes, thyroid or glandular disorder, cancer, tumour or growth including breast lumps or skin lesions/moles (even if you have not seen a doctor)?
b Back or neck pain/disorder, musculo-skeletal symptoms or any joint disorder, gout, arthritis, RSI, Paralysis of any kind or chronic fatigue syndrome, epilepsy or neurological disorder, mental/nervous disorder including stress, anxiety or depression?
c Kidney, bowel, bladder, gall bladder, liver disease or disorder, hepatitis, hernia, blood disorder, sleep apnoea, asthma, persistent cough or any lung complaint, any abnormality of hearing, speech or eyesight (excluding glasses or contact lenses)?
d To the best of your knowledge are you suffering from Acquired Immune Deficiency Syndrome (AIDS), infected with HIV or carrying antibodies to HIV?

If you have answered yes to any of the above health questions you are required to complete a Full Personal Statement in order to apply for cover.
Cover Required
$750,000 Death & TPD Cover

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