QSuper Form
Please complete in block letters, in blue or black ink.
1
Insurance Personal Statement
When should I use this form?
Do we
have all your
information?
You should complete this form if:
•
you have applied to change your cover using the Change of Insurance form or Member Online
and have been directed to this form because additional information is needed to assess your application.
•
you want to apply to have the pre-existing exclusion period removed from your cover.
•
you have previously cancelled your cover and are now applying for cover again.
Don’t complete this form if you have just started your job, as you’ll soon be receiving a welcome letter
that will outline what insurance you have.
Be sure to read the Accumulation Account Insurance Guide before filling out this form.
Just head to qsuper.qld.gov.au or call us and we’ll send you a copy.
1
Personal details
Client number
Title
Your client number can
be found on your annual
statement or by logging in
to Member Online.
Given names
Surname
Residential address
State
Postcode
As above
Postcode
We are committed to fast assessment of your application. To do
this, we may need to contact you for additional information to help
speed up the process.
Are you happy if we call/email you to clarify or gain further
information?
No
If ‘Yes’ please provide details below, if ‘No’ we will post you any
requested information.
Mobile phone number
Preferred contact time
Landline phone number
Preferred contact time
Email address
You are applying to enter into a contract of insurance. You have a
duty to disclose all relevant information. Failing to provide QSuper
with full and accurate information could result in your insurance
cover being cancelled and any claim for insurance benefit could be
denied, so it is really important you answer all questions fully and
to the best of your knowledge.
This obligation applies to all insurance cover relating to this
application, including any transfers from another fund.
Your Duty of Disclosure continues until you receive written
confirmation from QSuper that your application has been accepted.
State
Yes
Your Duty of Disclosure explained
(honesty statement):
We ask you specific personal questions via this personal statement.
In answering our questions you need to tell us about any
information that will impact on the decision by QSuper’s Insurer to
offer you insurance cover, regardless of whether you consider it to
be important or trivial. This includes your current health and any
medical tests or procedures that require investigation, are ongoing,
medication or treatment, even if a medical diagnosis is pending.
Date of birth (dd/mm/yyyy)
Postal address
2
You must contact QSuper if there are changes to your health or
personal circumstances that may be relevant to our decision on
your application.
The full Duty of Disclosure is contained at the end of this
document and it is important you read it carefully. Having
read the above, I declare the information I am about to provide is
honest, true and complete.
Member name
Member signature
Date (dd/mm/yyyy)
2
Insurance Personal Statement
3
Tell us the total amount of cover you want
b) Income support benefits from any source including workers‘
compensation, disability pension, veteran affairs or income
protection benefits (replacing all or part of your income while
unable to work as a result of accident/injury or sickness)?
Death cover (include any cover you already hold and want
to keep)
Fixed amount ($3,000,000 max)
Yes
Number of units
No
OR
Total and permanent disability cover (include any cover you
already hold and want to keep)
Q5.In the last 3 years, have you ever suffered from, sought
medical treatment or been hospitalised for:
a) Malignant cancers/tumours, diabetes mellitus (types I and
II) or any form of aneurysm.
Number of units
Fixed amount ($3,000,000 max)
OR
b) Multiple sclerosis, cerebral palsy, any form of plegia or any
neurological disorder.
Income protection cover
Number of units (units are worth $500 per month each)
c) Stroke, heart attack and/or disease, lung disease
(excluding asthma), sleep apnoea.
d) Liver or kidney disease, organ transplant as a recipient,
alcohol or drug abuse.
(If you have salary based cover of 87.75% of insured salary,
and wish to keep this level of cover you don’t need to complete
this field.)
Benefit period
3 years
5 years
Age 65
Waiting period
30 days
60 days
90 days
e) Hepatitis B or C, HIV or AIDS.
f) Auto-immune diseases, chronic pain, fibromyalgia,
ankylosing spondylitis.
g) Mental health disorders including bipolar, mood or
adjustment disorders, schizophrenia, stress, PTSD, panic
attacks, depression and/or anxiety.
h) Huntington’s disease, Parkinson’s disease, Alzheimer’s
disease (or any form of dementia), or Motor Neuron
disease
I am requesting removal of a pre-existing exclusion period
on any existing cover.
I want to cancel cover that I currently hold that I have not
listed above.
Yes
No
Q6. What is your current height and weight?
4
General health questions
Before we can make any changes to your insurance we need to
know about your general health and insurance history. Complete
this section to tell us about your general health history. You don’t
need to complete this section if you are returning this form with
a Change of Insurance form.
Q1.
Are you currently off work, restricted or unable to fully
perform without limitation all the duties of your usual
occupation on a full-time basis (for at least 30 hours per week),
due to sickness, illness or injury, even if your actual employment
may be full-time, part-time, casual or contract basis?
Yes
No
Q2. Have you been advised or diagnosed with a sickness,
illness or injury that reduces or is likely to reduce your life
expectancy to less than 24 months?
Yes
No
Q3. Have you ever been refused or declined death, total and
permanent disability (TPD) or income protection cover
(either in Australia or overseas) due to a sickness, medical
condition or injury?
Yes
No
Q4. Have you ever been paid a claim or are you eligible to be
paid, or currently receiving or in the process of submitting
a claim through any of the following:
a) Any insurance policy inside or outside super, (whether
with QSuper or another provider), for death, total and
permanent disability (TPD) or terminal illness benefits?
Height
Weight
cm
5
kg
Occupational rating questions
You’ll need to complete these questions before we can assess your
application. These questions refer to the role you spend the most
time performing. You don’t need to complete this section if you
are returning this form with a Change of Insurance form.
Q1. Are you:
• a registered or enrolled nurse or assistant in nursing who is
qualified and currently practicing, or
• working in the retail sector, or food and beverage service?
Yes
No
Q2. Are you:
• a qualified tradesperson currently working within your area
of expertise (e.g. hairdresser, chef, plumber, electrician,
plasterer, carpenter or concreter), or
• a skilled worker with light manual duties (e.g. jeweller,
building inspector, laboratory technician, foreman or office
equipment technician)?
Yes
No
3
Insurance Personal Statement
Q9. What is your occupation?
Q3. Are you:
• a police officer, firefighter, paramedic, or other emergency
or protective services worker, including security guard or
corrections officer, or
Industry (e.g. finance, mining, retail)
• a professional sportsperson, or
• working in a manual occupation which does not require
trade qualifications and may be subject to accident or
environment hazards (e.g. earthmover, driver, cleaner,
labourer, factory worker or agricultural worker)?
Yes
No
Q4. Are the usual work activities of your job considered office
based or school teaching (meaning you spend at least 80%
of your work time doing clerical, call centre, administrative
or other office or classroom based activities), or
Are you a medical practitioner, lawyer or engineer who
spends at least 80% of your work hours in an office or
clinical environment?
Yes
Q1.Are you an Australian resident, or hold a permanent
residency to reside in Australia? (Australian resident has a
specific meaning that can be found in the Definitions section
of the Accumulation Account Insurance Guide.)
Yes
No
Q2. Are you currently working?
Yes
• being underground (in construction and mining
environments) or underwater for more than 20% of total at
work time, or
• working at heights over 20 metres in any environment
requiring hard hat and harness for safety by law, or
What is your current annual income (gross income before tax,
excluding super)?
Q3. What is your employment status?
• handling firearms (other than as a police officer, correctional
officer or licensed security guard), dangerous chemicals or
explosives, or
• offshore work – oil and gas platforms or ships at sea, or
No
$
No
Q5. Do you currently perform, or intend to work in a job within
the next 3 months that includes, any of the following risky
activities:
Employment and income questions
6
Self-employed
Full-time
Part-time
Casual
Contractor
Student
Home maker
Unemployed
Retired
Q4.If you are working, what is the number of hours you
consistently work per week?
Under 15 hours
15 to 55 hours
Greater than 55 hours
Q5. Do you intend to take parental leave in the next six months?
Yes
No
Dates (dd/mm/yyyy) – (dd/mm/yyyy)
• crop dusting, aerial mustering or any low level flying activity
(defined as below 150m or 500ft), or
• flying more than 200 hours per annum as a passenger other
than on a commercial airline, or as a pilot (fixed wing or
helicopter)
Yes
No
Q6. A
re you earning more than $120,000 a year, (before tax and
employer paid superannuation), from your job?
Yes
No
Q7. Do you have a university qualification which you are using/
is required in your current role?
Yes
Q6. In the last 5 years have you sought HR advice or undergone
counselling and/or performance management for work related
issues?
Yes
No
If ‘Yes’, please complete the fields below:
Company/employer
Reason
No
Dates (dd/mm/yyyy) – (dd/mm/yyyy)
Q8. Do you have a senior/executive level management role in
your company? (your direct reports would be mid-level
managers or skilled specialists in a sedentary setting), or
Is your role considered professional (e.g. doctors, solicitors,
accountants – requiring membership of a professional or
government body to practise in your occupation)?
Yes
No
4
Insurance Personal Statement
Company/employer
Reason
Dates (dd/mm/yyyy) – (dd/mm/yyyy)
Company/employer
Reason
Dates (dd/mm/yyyy) – (dd/mm/yyyy)
Q6. Do you intend in the next 12 months, to claim
unemployment benefits?
Yes
No
Q7.Are you or do you intend to claim benefits under any insurance
plan, government/employment scheme, armed forces
scheme, police scheme, pension, Workers’ Compensation
or allowance, or as a result of court proceedings?
Yes
No
If ‘Yes’ to Q6 and/or Q7, please complete below table:
Benefit type/reason
Dates (dd/mm/yyyy) – (dd/mm/yyyy)
Benefit type/reason
Dates (dd/mm/yyyy) – (dd/mm/yyyy)
Benefit type/reason
Dates (dd/mm/yyyy) – (dd/mm/yyyy)
If you intend to claim more than three benefits, please
provide information about the benefit at the end of this
form or attach a separate sheet with the details.
5
Insurance Personal Statement
7
Tell us what other life insurance cover you have
Q1.Other than this application, do you have or have you recently applied for any life, total and permanent disablement or income
protection cover under any other insurance policy or under any superannuation scheme?
Yes (complete below)
Insurer
No
Type of cover
Insured amount
To be replaced
Policy number
$
Yes
No
$
Yes
No
$
Yes
No
$
Yes
No
Date policy commenced
Q2.Have you ever had an application for life, income protection, total and permanent disablement, trauma, accident or sickness
insurance on your life declined, deferred or accepted with special terms, e.g. a loading or exclusion?
Yes (complete below)
Insurer
No
Type of cover
Terms offered
Reasons for terms
Date
If you need to list more, please attach a separate sheet with the details.
8
Tell us about your lifestyle
Q1.Have you used tobacco, including chewing tobacco, cigars or a pipe within the past 12 months, or used a product containing
nicotine e.g. nicotine patches or gum in the last 3 months?
Yes (tell us your average tobacco or nicotine use in only one below)
Type smoked/used
No
Per day
Per month
Cigarettes
OR
Other – specify type
OR
If you’ve stopped using tobacco within the last 12 months or a product containing nicotine in the last 3 months, what date did you stop?
Date (dd/mm/yyyy)
Q2. Do you drink alcohol?
A standard drink is equivalent to: 1 nip of spirits, 1 glass of wine, 250ml of beer.
Yes (indicate average number of standard drinks in only one below)
Per day
Per week
OR
No
Per month
OR
Per year
OR
6
Insurance Personal Statement
Q3.Have you ever taken (by any method) any illegal drugs or
prescribed medications in excess of prescribed dosages,
received or been advised to seek counselling or treatment
for the use of alcohol or substance abuse?
Yes (complete below)
No
What substance did/do you take and how?
When did you start taking them? (dd/mm/yyyy)
When did you last take these substances?
I received counselling and/or treatment for the above described
substance abuse / misuse.
Yes
No
When did you receive counselling/advice/treatment?
Start:
9
Last:
Pastimes and activities
Q1. Do you engage or intend to engage in any of the following
activities?
a) Aviation (other than as a passenger on a recognised
carrier)?
Yes
No
b) Scuba diving (below 30 metres and/or into wrecks or
caves)?
Yes
No
c) Motor sports of any kind (e.g. motor cross, rally driving,
ocean racing, trail bike and quad bike riding)?
Yes
No
d) Football of any code (excluding touch football and Oztag)?
Yes
No
e) Any other sport or hazardous activities (e.g. parachuting,
hang-gliding, long-distance sailing, mountaineering)?
Yes
No
If you have answered ‘Yes’ to any of the above, please
complete the specific questions on the related activity in
sections 18-22.
7
Insurance Personal Statement
10 Doctor details
Q1. Please provide the name and address of the last doctor or medical centre you consulted?
If ‘Yes’ to any of the previous, please provide details in table below.
Relationship to you
Doctor’s name or medical centre
Condition
Address
Approximate age of onset
State
Age at death (if applicable)
Postcode
Phone number
Relationship to you
Email address
Condition
Q2. Have you been a patient of this doctor or medical centre for less than 12 months?
Yes
Approximate age of onset
No
If ‘Yes’, please provide details of your previous doctor or
medical centre you consulted.
Age at death (if applicable)
Relationship to you
Doctor’s name or medical centre
Condition
Address
Approximate age of onset
State
Age at death (if applicable)
Postcode
Phone Number
If you need to include additional family members, please
provide information at the end of this form or attach a
separate sheet with the details.
Email Address
Q3. How many visits/consultations have you had with your doctor(s) in the last 2 years?
0-5
6-9
10+
11 Family history details
Q1. To the best of your knowledge, have any of your biological parents, brothers or sisters ever suffered from or been diagnosed with any of the following:
a) Heart problems, stroke, high blood pressure, diabetes.
Yes
No
Unknown
No
Unknown
c) Cancer of any type (specify type of cancer in table below
e.g. breast, ovarian, bowel or colon).
Yes
No
Unknown
d) Huntington’s disease, muscular dystrophy, polycystic
kidney disease or any other hereditary disease.
Yes
No
Q1.Have you ever experienced symptoms, received advice,
diagnosis or treatment for any back, neck or joint disorder of
any kind, including but not limited to disorders of the spine,
its muscles and nerve roots eg: sciatica, disc bulge, back pain
AND / OR disorders of the shoulders, elbows, knees, hips or
any joint (includes bone, muscle and connective tissue)?
Yes
b) Mental health disorder.
Yes
12 Medical history details
Unknown
No
Q2. Have you ever received medical advice, been treated
for or diagnosed with depression or a mental health
condition, including but not limited to anxiety, stress,
tiredness/lethargy, panic attacks, post-natal depression,
post-traumatic stress, behavioural or nervous disorder,
Asperger’s syndrome or attention deficit disorder?
Yes
No
8
Insurance Personal Statement
Q3. Have you ever had or sought advice or treatment for,
experienced symptoms of or suffered from any of
the following?
a) Asthma, bronchitis, emphysema or any other lung complaint.
Yes
No
b) Cyst, mole, sunspots, skin lesion, skin cancer.
Yes
No
c) Diabetes or abnormal blood sugar.
Yes
No
d) High blood pressure or raised cholesterol.
Yes
No
o) Any impairment of sight (other than corrected by glasses
or lenses), hearing or speech including tinnitus or blurred
vision.
Yes
No
p) HIV and/or AIDS including diagnosis and known or
suspected exposure, or are you awaiting results of an HIV test.
Yes
No
q) Any previous sexually transmitted diseases.
Yes
No
If yes, provide more details below.
Q4. Have you ever had or sought advice or treatment for,
experienced symptoms of or suffered from any of the following?
a) Chest pains, heart problems, heart murmur, palpitations
or rheumatic fever.
Yes
No
b) Stroke, paralysis, neurological disorder, blood vessel
disorder.
Yes
No
c) Cancer, tumour or melanoma.
Yes
No
d) Thyroid, glandular or pancreatic disorder.
Yes
No
e) Persistent indigestion, irritable bowel, gastric or duodenal
ulcer, or other bowel disorder.
Yes
No
f) Any disorder of the gall bladder or liver (including
hepatitis B, C or raised liver function).
Yes
Q5.Have you ever had any other illness, disease, disorder,
do not include: colds, flu, hay fever, dental matters,
menopause, uncomplicated pregnancy (including
caesarean section, miscarriage, abortion).
Yes
No
Q6.Have you ever had any medical examinations,
consultations, X-rays, genetic or pathology tests or
procedures in the last 5 years relating to a matter not
previously disclosed in this application?
Yes
No
Q7. If not previously stated in this application, are you regularly
taking any stimulants, sedatives, or prescribed medication (do
not include non-prescribed medication e.g. paracetamol)?
Yes (Please provide details below)
Type of medication
No
Frequency of use
No
g) Varicose veins, haemorrhoids or hernia.
Yes
No
h) Disorder of the kidney, bladder or prostate, blood in urine
or kidney stones.
Yes
No
i) Epilepsy, fits of any kind, fainting episodes or recurring
headaches or migraines.
Yes
No
j) Lethargy, sleep apnoea or any sleeping disorder.
Yes
No
k) Arthritis, gout or osteoporosis.
Yes
No
l) Fibromyalgia, repetitive strain injury (RSI), or any other
chronic pain syndrome.
Yes
No
m) Psoriasis, eczema, dermatitis or any other skin disorder.
Yes
No
n) Anaemia, leukaemia, haemophilia, haemochromatosis
or any other blood disorder.
Yes
No
If you need to list additional medications, please attach a
separate sheet with the details.
Q8. For completion by FEMALES ONLY.
Have you ever had or sought advice or treatment for,
experienced symptoms of or suffered from any of the following:
a) Any breast lump (even if you have not seen a doctor)
or any abnormal mammogram or breast ultrasound.
Yes
No
N/A
b) An abnormal cervical smear test, including the detection of
human papilloma virus (HPV) or any abnormality of the ovaries.
Yes
No
N/A
c) Abnormal vaginal bleeding within the last 12 months.
Yes
No
N/A
d) Are you pregnant? (if yes, please provide estimated
due date).
Yes
No
Due date (dd/mm/yyyy)
N/A
9
Insurance Personal Statement
If you answered ‘Yes’ to Section 12:
• Q1, 2 and 4 to 8 then please complete the health questions in Section 13 below
• Q3a then please complete Section 14
• Q3b then please complete Section 15
• Q3c then please complete Section 16
• Q3d please complete Section 17
13 Your health
In relation to
Question:
Question:
Question:
Name of condition
Date symptoms first started
Date symptom ceased
(if ongoing please state)
Ongoing
Ongoing
Ongoing
How often do/did you have
symptoms? Please choose from
one of the following: daily, weekly,
monthly, quarterly, half-yearly,
yearly, one-off, other
– please specify.
Severity of condition – please
choose from one of the following:
mild, moderate, severe,
symptom free, symptoms
ceased.
Have you ever had an X-ray, scan
or blood test for this condition?
Did you take medication or
have any other treatment (e.g.
physiotherapy, operation) for
this condition? If ‘Yes’, name the
treatment/medication.
Are you still on treatment
(including medication)?
Yes
No
Yes
No
Yes
No
Details
Details
Details
Dates (dd/mm/yyyy)
Dates (dd/mm/yyyy)
Dates (dd/mm/yyyy)
Results
Results
Results
Yes
No
Details
Yes
Yes
No
Details
No
Yes
Yes
No
Details
No
Yes
No
If you need to include information about additional conditions, please provide information at the end of this form or attach a separate
sheet with the details.
10
Insurance Personal Statement
Have you ever been off work as
Yes
a result of this condition? If ‘Yes’,
please state the total time off work Details
in days, months or years.
No
Have you had any residual,
ongoing effects or restrictions as
a result of this condition? If ‘Yes’,
please provide dates and details.
No
Yes
Yes
No
Details
Yes
Yes
Details
No
Yes
Details
Details
Details
Dates
Dates
Dates
Is your treating doctor/medical
Yes
No
centre different from your usual
doctor? If ‘Yes’, please provide the Name of doctor/specialist
doctors details.
Yes
No
No
Yes
No
No
Name of doctor/specialist
Name of doctor/specialist
Doctor’s address
Doctor’s address
Doctor’s address
State
State
State
Postcode
Postcode
Phone number
Phone number
Phone number
Email address
Email address
Email address
Postcode
11
Insurance Personal Statement
14 Asthma, bronchitis or any other lung
complaint questions
a) Please tick the appropriate box(es)
15 Cysts, moles, sunspots or skin lesion
complaint questions
a) Please tick the appropriate box(es)
Asthma
Cyst
Mole
Bronchitis
Sunspot
Skin lesion
Other (please specify):
Melanoma
b) Frequency of symptoms in the last 2 years?
Please tick the appropriate box(es)
Other (please specify):
b) Location of growth/s (e.g. face, back, right arm)
Daily
Weekly
Occasionally
c) Have you been advised that your growth/s or skin lesion
were cancerous or malignant?
One-off episode
Yes
None, childhood only
d) How many growths or skin lesions did you have?
c) Severity of symptoms?
Please tick the appropriate box(es)
Mild – infrequent attacks, exercise induced
or seasonal.
Moderate – frequent symptoms, no specific triggers,
occasional oral steroid therapy.
Severe – very frequent attacks and wheezing, may restrict
work duties and frequent use of oral steroids.
d) In the last 2 years have you required hospitalisation or
emergency treatment for your respiratory condition?
Yes
No
e) Have all your growths or skin lesions been removed or
treated?
Yes (complete below)
No
How were they removed or treated?
Please tick the appropriate box(es)
Surgically removed/cut off.
Frozen/burnt off/cream.
No
e) In the last 12 months has this caused you to have time
off work?
Yes (complete below)
No
Number of consecutive days you had off work in the last
12 months?
Date/s of removal (dd/mm/yyyy)
f) Were any further tests, investigations, treatments or follow
ups recommended?
Yes (complete below)
No
Please provide dates and outcomes of any
recomendations that were completed.
f) Is your treating doctor different from the last doctor
you consulted?
Yes (complete below)
No
g) Is your treating doctor different from the last doctor
you consulted?
Doctor’s name or medical centre
Yes (complete below)
Address
No
Doctor’s name or medical centre
State
Postcode
Address
Phone number
Email address
State
Phone number
Email address
Postcode
12
Insurance Personal Statement
16 Diabetes and abnormal blood
sugar questions
17 High blood pressure and raised
cholesterol questions
High blood pressure
a) Please tick the appropriate box(es)
Diabetes (go to b).
a) When were you first diagnosed with this condition?
Abnormal blood sugar (go to c).
Within the last 12 months.
b) What type of diabetes do you have?
Please tick the appropriate box(es)
More than 12 months ago.
b) Do you have any problems or complications resulting from
this condition? (e.g. heart disease, kidney disorder)
Type 1 – insulin dependant.
Type 2 – diet controlled, oral medication.
c) At what age were you diagnosed with this condition?
Yes
c) Are you taking regular medication for this condition?
Yes
d) In the last 6 months, have you had a HbA1c (Glycosylated
Haemoglobin) or fasting blood sugar/glucose level test?
No (go to e)
Yes (please provide results below)
HbA1c (Glycolsylated Haemoglobin)
Please tick the appropriate box
No
No
d) Is your blood pressure being monitored by your doctor and
considered to be well controlled? (e.g. less than 140/90)
Yes
No, go to e
e) Is your treating doctor different from the last doctor
you consulted?
Yes, complete below
Up to 6.0 mmol.
6.1 to 8.0 mmol.
No
Doctor’s name or medical centre
8.1 or more mmol.
Don’t know.
Address
Abnormal blood sugar
Please tick the appropriate box
Up to 6.6 mmol.
State
6.7 to 8.0 mmol.
Phone number
8.1 or more mmol.
Don’t know.
Email address
e) As a result of your condition, have you ever experienced
complications such as eye problems, numbness or tingling
in your legs or feet, a diabetic or insulin coma?
Yes
Postcode
No
Raised cholesterol
a) When were you first diagnosed with this condition?
f) Is your treating doctor different from the last doctor
you consulted?
Yes (complete below)
No
Within the last 12 months.
More than 12 months ago.
b) Are you taking regular medication for this condition?
Doctor’s name or medical centre
Yes
No
c) When was your last cholesterol reading?
Address
Within the last 12 months.
More than 12 months ago.
State
Phone number
Email address
Postcode
d) What was the result of your last cholesterol reading?
Please tick the appropriate box
2.0 to 5.9 mmol.
6.0 to 6.9 mmol.
7.0 or above mmol.
Don’t know.
e) Is your treating doctor different from the last doctor
you consulted?
Yes, complete on p13
No
13
Insurance Personal Statement
Doctor’s name or medical centre
Ballooning
Number of hours flown
in the last 12 months
Address
Number of hours in the
next 12 months
Gliding
State
Postcode
Number of hours flown
in the last 12 months
Number of hours in the
next 12 months
Phone number
Hang gliding
Email address
Number of hours flown
in the last 12 months
If you answered Yes to Section 9:
• Q1a, then complete Section 18
• Q1b, then complete Section 19
Number of hours in the
next 12 months
Ultra-light/gyroplanes
Number of hours flown
in the last 12 months
Number of hours in the
next 12 months
• Q1c, then complete Section 20
• Q1d, then complete Section 21
• Q1e, then complete Section 22
Parachuting/paragliding/skydiving
Number of hours flown
in the last 12 months
18 Flying questions
Aerobatics/stunt
a) What type of aircraft do you fly? Please tick the appropriate
box(es).
Fixed wing (private/recreational/commuter travel)
Number of hours flown
in the last 12 months
Number of hours in the
next 12 months
Number of hours in the
next 12 months
Number of hours flown
in the last 12 months
Number of hours in the
next 12 months
a)
b) Do you hold an air service licence?
Yes
No
c) Do you intend to change the scope of your present licence?
Fixed wing (charter flying)
Number of hours flown
in the last 12 months
Yes (complete below)
Number of hours in the
next 12 months
No
Please state the change in scope of your present licence
Helicopter (charter flying)
Number of hours flown
in the last 12 months
Number of hours in the
next 12 months
Fixed wing and helicopter (agriculture/crop/mustering)
Number of hours flown
in the last 12 months
Yes (complete below)
Please provide details
No
Number of hours in the
next 12 months
Helicopter (private/recreational/commuter travel)
Number of hours flown
in the last 12 months
d) Have you ever had an accident or been charged with
violating civil aviation regulations?
Number of hours in the
next 12 months
e) Do you intend to engage in any form of aviation other than
already mentioned?
Yes (complete below)
Please provide details
No
14
Insurance Personal Statement
f) Do you ever use unauthorised landing areas?
Yes (complete below)
20 Motor sports of any kind questions
No
a) What type of vehicle or motor activity do you engage in?
Please provide details
b) At what level do you participate?
Recreational only (non-competition).
19 Underwater diving questions
Amateur including regular or occasional organised,
unpaid competition.
a) At what level do you participate?
Semi-professional/professional.
Recreational only (non-competition).
c) Have you ever been involved in any accidents while
practising, testing or racing?
Amateur including regular or occasional organised,
unpaid competition.
Yes (complete below)
Semi-professional/professional.
b) How many times per year do you participate in this activity?
No
Provide details of when this occurred and whether you have
any restrictions of your work duties or activities as a result
c) Do you ever dive:
Alone? e.g. without a buddy.
Yes
No
Over 30 metres in depth?
Yes
No
In wrecks, caves or potholes?
Yes
No
If ‘Yes’ to any of the above, please provide details
d) Do you participate in record attempts or prototype testing?
Yes
No
e) Which events do you race in?
Please provide details
d) Have you ever had a diving accident, suffered from
decompression sickness, the bends, or burst eardrums?
Yes (Provide details below)
No
e) What type of diving qualification do you hold?
No qualification
PADI
NAUI
BSAC
Other (please specify):
f) How many times per year do you participate in this activity?
15
Insurance Personal Statement
21 Football of any code questions
a) What type of football code do you participate in?
Rugby league
Australian Rules Football
American football (gridiron)
Soccer
b) At what level do you participate?
Recreational only (non-competition).
Amateur including regular or occasional organised unpaid
competition.
Semi-professional/professional.
c) In the last 2 years have you had an injury that required any
time off work?
No
d) Do you receive an income from participating in this activity?
Yes (complete below)
You can return your competed form to us via email or mail.
To email us, simply scan your completed form and send it as
an attachment to [email protected].
You’ll need to include your surname and client number in
the subject line.
Rugby union
Yes (complete below)
Additional information about this form
No
At QSuper we value your security and recommend that you
don’t keep copies of sensitive personal information in your email
account to protect yourself in the event your email account is
ever hacked. After sending your form to us, please check your
‘sent items’ folder and delete any email containing the completed
form, and also empty all deleted items from your mailbox. It’s also
recommended not to keep the completed form in a cloud storage
facility such as Dropbox or Google Drive.
If you don’t want to use email, you can return your completed
form to:
Attention: Underwriting
QSuper
GPO Box 200
Brisbane QLD 4001
The information you’ve provided will be used to assess
your application to change your insurance. You should
keep a copy of your completed form as you may want to
refer to it in the future.
How much do you earn from this activity per year?
$
On the following page, please complete:
22 Other sport or hazardous activities
a) What activity do you engage in?
b) At what level do you participate?
Recreational only (non-competition).
Amateur including regular or occasional organised,
unpaid competition.
Semi-professional/professional.
c) How many times per month do you play or participate in
this activity?
d) Do you receive an income from participating in this activity?
Yes (complete below)
No
How much do you earn from this activity per year?
$
• Your declaration and authorisation
• Medical history authorisation
16
Insurance Personal Statement
23 Your declaration and authorisation
Your duty of disclosure
You have a duty to tell QSuper and its insurer anything that you know, or could reasonably be expected to know, that may affect our decision
to insure you and on what terms. You have this duty until we agree to insure you. You have the same duty before you extend, vary or reinstate
the contract. You don’t need to tell us anything that:
•
•
•
•
reduces the risk we insure you for; or
is common knowledge; or
we know or should know through our insurer; or
we waive your duty to tell us about.
If you do not tell us something
In exercising the following rights, the QSuper Board as Trustee for the QSuper Fund (referred to as ‘QSuper’), and its insurer may consider whether
different types of cover can constitute separate contracts of life insurance. If we do, we may apply the following rights separately to each type of cover.
If you don’t tell QSuper and its insurer anything you are required to, and we would not have insured you if you had told us, we may void
the contract within three years of entering into it. If QSuper and its insurer void the contract, we may reduce the amount you have been
insured for. This would be worked out using a formula that takes into account the premium that would have been payable if you had told us
everything you should have. However, if the contract provides cover on death, QSuper and its insurer may only exercise this right within three
years of entering into the contract. If QSuper and its insurer void the contract or reduce the amount you have been insured for, we may, at any
time vary the contract in a way that places us in the same position we would have been in if you had told us everything you should have. If
your failure to tell QSuper and its insurer is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.
By signing this application, I am making the following statements:
•
•
•
•
•
I have read the Product Disclosure Statement for the Accumulation Account and Income Account and the Accumulation Account Insurance Guide.
I have read the Your Privacy factsheet and I understand how QSuper will collect, use and disclose my personal information.
I have fully read and understood this form and the information I’ve given in this application and any separate statements I have given with
it are true. I have complied with my duty of disclosure and have disclosed everything about me and my health that QSuper and its insurer
need to know when deciding whether to accept my application for cover.
I authorise QSuper’s insurer to refer to any statements that have been made in connection with my application for insurance and any
medical reports to other entities involved in providing or administering my insurance (for example reinsurers, third party administration
or specialist claims providers and legal advisers) or persons appointed to obtain financial, employment or medical related information in
support of the assessment of my claims from any other entity holding information on me.
I understand that my duty of disclosure continues until I receive written confirmation from QSuper that my application has been
accepted.
Signature of the person to be insured
Name
Date (dd/mm/yyyy)
Medical history authorisation (must be completed)
To whom it may concern
I authorise any doctor, hospital, clinic and other medical or related facility, or any other person who has attended me, to provide QSuper and
its insurer with any information with respect to any sickness, injury, consultation, tests (including genetic tests), prescriptions or treatment and
copies of all hospital records. I authorise Medicare Australia to release to QSuper and its insurer, at their request, a copy of my medical history
records. I agree that a photocopy or facsimile of this authority should be considered as effective and valid as the original.
Member’s name
Member’s signature
Date (dd/mm/yyyy)
17
Insurance Personal Statement
Adviser authorisation (to be completed only by a financial adviser who is acting on your behalf)
For what reason is the information in this Insurance Personal Statement being provided?
Transfer of insurance (ordinary to super or super to super)
Adding or removing cover options
Underwriting pre-assessment details
Pre-assessment underwriting reference number (if applicable)
If the applicant has a significant medical condition or is overweight/obese, have you pre-positioned your client that non-standard terms or a
decline may apply?
Yes
No
Concurrent applications
Are you submitting any life or disability insurance applications for this customer(s) through any other insurer. If Yes, please include:
Product name
Proposal/Policy number
English literacy
Can the proposed life insured read and understand English?
Yes
No
If no, what language was used to explain the policy?
Your details
Adviser 1 name
Adviser 2 name
Agency name and AFSL
Agency name and AFSL
Agency’s ABN/ACN
Agency’s ABN/ACN
Phone number
Fax number
Phone number
Fax number
Adviser declaration
I certify that I have provided the applicant with the current Accumulation Account Insurance Guide.
Signature of Adviser 1
Date
Signature of Adviser 2
Date
Member declaration
(If applicable) I authorise QSuper and its insurer to provide the financial adviser listed above with information relating to my application for
insurance including copies of any statements or medical reports which may include information about my health, financial and insurance
information.
Member’s signature
Date
18
Insurance Personal Statement
Provide additional information here
19
Insurance Personal Statement
This page has been left blank intentionally.
Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane
Telephone 1300 360 750 (+617 3239 1004 if overseas)
Monday – Friday 8.30am to 5.00pm Queensland time
Postal address Underwriting, GPO Box 200, Brisbane Qld 4001
Fax 1300 242 070
Website qsuper.qld.gov.au
ABN 60 905 115 063
SFN 261041941
10408 24/03/17 FO113
This form and all products are issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN 32 125 059 006) (QSuper Board) as trustee for the State Public Sector
Superannuation Scheme (ABN 60 905 115 063) (QSuper Fund). We’re collecting personal information from you to assess your eligibility for personalised cover . We may also collect information from
your employer, government agencies, other superannuation funds, and anyone you authorise, and if it is required or authorised by law (including pursuant to the Superannuation (State Public Sector)
Act 1990 (Qld) and Anti-Money Laundering and Counter-Terrorism Financing Act 2006 (Cth)). We may disclose your information to your employer, authorised service providers (including QInsure Limited
ABN 79 607 345 853 (QInsure) and any of its authorised service providers), other superannuation funds and government agencies and to third parties if we need to, if you’ve given consent to the
disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet from our website or call us on 1300 360 750 and ask for a copy.
© QSuper Board of Trustees 2017