Nomination of Beneficiary
SECTION 1: MEMBER DETAILS
Mr / Mrs / Ms / Miss
Last Name
First Names
Full Postal Address
IRD No
Date of Birth
Phone
Mobile
Employee No.
Email*
Work Location
*By providing my email address, I am consenting to receiving information about the Scheme (including the annual report) electronically, including by way of a
hyperlink. Should I not wish to receive such information electronically, or should my email address change, I undertake to advise the Scheme’s administration
manager (Mercer) whose contact details are on page 2 of the this form.
I declare that this nomination revokes any previous nomination made by me. My signature below authorises the disclosure of the
information relating to my nominated beneficiaries to such parties as are necessary for the purposes of the Scheme. I further
acknowledge that while the Trustee will take my nominations into account, it has final discretion as to how and in what proportions
my death benefit is paid.
Signed
Date
As a member of the Dairy Industry Superannuation Scheme (‘the Scheme’) I advise that in the event of my death I would like the
Trustee to pay my benefit (excluding any Locked-In (Complying Fund) Account balances) in the proportions stated, to the following.
SECTION 2: NOMINATED BENEFICIARY DETAILS
Please note:
You may only nominate any natural person you would like the Trustee to consider (this person must be accepted in writing by the
Trustee) or nominate your personal representatives who are the executors of your Will or the administrator of your estate if you die
without a Will.
Although the Trustee will normally be guided by your wishes, the Trustee has absolute discretion in deciding to whom and in what
shares the benefit is paid.
Any Locked-In (Complying Fund) Account balances will be paid to your personal representatives (the executors of your Will or
administrators of your estate if you do not have a Will).
1. Name
Address
Relationship
Proportion of benefit
%*
Proportion of benefit
%*
2. Name
Address
Relationship
IMPORTANT: Please
Please remember
to sign
the form
ensure
have completed
1 above.
IMPORTANT:
remember
to sign
theand
form
andyou
ensure
you haveSection
completed
Section 1 above.
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3. Name
Address
Relationship
Proportion of benefit
%*
Proportion of benefit
%*
Proportion of benefit
%*
Proportion of benefit
%*
Proportion of benefit
%*
Proportion of benefit
%*
Proportion of benefit
%*
4. Name
Address
Relationship
5. Name
Address
Relationship
6. Name
Address
Relationship
7. Name
Address
Relationship
8. Name
Address
Relationship
9. Name
Address
Relationship
*The percentages you nominate must equal 100% when totalled.
PLEASE RETURN TO THE DAIRY INDUSTRY SUPERANNUATION SCHEME
C/- MERCER (N.Z.) LIMITED, PO BOX 1849, WELLINGTON 6140, NEW ZEALAND.
TELEPHONE: 0800 355 900 FAX: 04 819 2699
Updated September 2016
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