Professional Documents
Culture Documents
3 Reduce my cover
Member number:
Death Cover:
From
Date of birth:
D D
M M
Title: Ms
Mrs
M
Gender: F
Given name/s:
Mr
units
Y Y Y Y
Miss
units to
Dr
Other
Family name:
From $
to $
units to
From $
units
to $
^Lump-sum TPD Cover cannot exceed Death Cover.
2 Cancel my cover
From $
per month
to $
per month
or
Reduce my IP Cover from an expiry age of 67 with
a 2-year benefit period, to an expiry age of 60 with
a 2-year benefit period.
IP waiting periods:
Please increase my IP waiting period from:
30-60 days
or
60-90 days
or
30-90 days
*Concessional super contributions and investment earnings are taxed at 15%. However, HESTA can deduct all or part of insurance fees from the amount that would be subject
to tax. The resulting tax saving is passed on to you as a lower net insurance cost. The net cost shown above is based on the full 15% tax deduction of insurance fees and is an
estimate. Actual outcomes may differ depending on HESTAs eligibility for tax deductions. Rounding has been applied to these figures.
Page 1 of 2
Non-disclosure
If you fail to comply with your duty of disclosure and the insurer
wouldnt have issued the cover if the failure had not occurred, the
insurer may avoid the cover within three years of issuing it. If your
non-disclosure is fraudulent, the insurer may avoid the cover at
any time.
Yes
I understand my cover will be rounded up to the nearest $1,000.
My sum insured will remain the same each year, however
insurance fees may increase each year.
Please note: for members over the age of 60, TPD Cover
amounts will reduce by 10% for each complete year after age 60.
If a member is over 60 when TPD Cover is fixed, the cover amount
will reduce in equal increments greater than 10% for each full
year until age 70 when cover for TPD stops completely.
No
No
(c) in the last 24 months, have you been unable to work because
of injury or illness for more than 5 consecutive days?
Yes
No
(d) have you been diagnosed with any illness that reduces your
life expectancy to less than 12 months from today?
Yes
No
5010 12/15
Contact us
An insurer who is entitled to avoid cover may elect not to avoid it,
but apply either of the following options:
reduce the sum that you have been insured for in accordance
with a formula that takes into account the insurance fee that
would have been payable if you had disclosed all relevant
matters to the insurer
vary the cover in such a way as to place the insurer in the
position it would have been in had the failure to comply with
the duty of disclosure not occurred.
If your cover is death cover, the insurer may only apply the first of
the two options and it must do so within three years of issuing
the cover.
6 Declaration
I am aware/understand insurance cover through HESTA will
only be provided as set out in the contract of insurance that
the Trustee of HESTA holds with the Insurer (as amended from
time to time)
In choosing to cancel or reduce my cover, I acknowledge I will
no longer be insured for that amount and type of cover. If I
decide I require insurance cover in the future, I understand that
I will need to apply to HESTA in writing and be required to
provide medical evidence.
I have read and understood the HESTA Privacy Collection
Statement and consent to the Trustee of HESTA collecting,
using and disclosing my personal information.
I declare the answers to all of the questions in the Personal
Statement (if completed due to changing from unitised to
fixed cover) and the declarations given by me are true and
correct (including those not in my own handwriting). I have
not withheld any information which may affect the Insurers
decision to provide insurance cover.
I have read and understand the Your duty of disclosure
and Non-disclosure sections, and have not withheld any
information that may affect the insurers decision as to
whether to accept my application for transfer of insurance
cover. I understand that the duty of disclosure continues
after I have completed this statement until I am notified of
acceptance in writing by the Trustee.
Members signature:
Date:
D D
M M
Y Y Y Y
hesta.com.au
Issued by H.E.S.T. Australia Ltd ABN 66 006 818 695 AFSL No. 235249, Trustee of Health Employees Superannuation Trust Australia (HESTA) ABN 64 971 749 321. Information provided is
of a general nature and is correct at the time of preparation. It does not take into account your objectives, financial situation or specific needs so you should look at your own financial position
and requirements before making a decision. You may wish to consult an adviser when doing this. For more information, visit hesta.com.au or call 1800 813 327 for a copy of a Product
Disclosure Statement (PDS) which should be considered before making a decision about HESTA products. The information you provide on this form, and any subsequent information you
provide to us or our service providers in relation to this form, is collected in accordance with the HESTA Privacy Collection Statement available at hesta.com.au/privacy or by calling 1800
813 327. Where you provide us with personal information about another person, it is your responsibility to notify that person about the disclosure of their personal information to us.
Page 2 of 2
Clear form