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

SMSF Name:*

Please enter full name of the Self Managed Super Fund

SMSF ABN:*

Please enter the Super Fund ABN, excluding spaces

Trustee Name (if company) :

Full name of Corporate trustee (if applicable)

Trustee names (if individual trustees) 1.

Full name of First Individual Trustee

2.

Full name of Second Individual Trustee (if applicable)

3.

Full name of Third Individual Trustee (if applicable)

4.

Full name of Forth Individual Trustee (if applicable)

Address Line 1:*

Address Line 2:

City:*

State:*

Post Code:*

Home Area Code:

Home Phone Number:

Mobile Phone Number:

Email:*

Title:*

Mr Mrs Miss Ms Dr

First Name:*

Surname:*

Date Of Birth:*

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905

Note: You must be under age 65 to apply for death cover and under age 60 to apply for TPD cover.

Gender:*

Male Female

Smoker:*

Non-Smoker Smoker

Occupation:*

White Collar Non White Collar

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.

Australian Resident :*

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.

Default

$750,000 Death & TPD Cover

Self Select