Insurance election FoC

Member Number *

First Name *

Last Name *

Mobile Phone Number *

Email Address *

Election to maintain Insurance Cover (All Members) *

YesNo

I elect to maintain all my insurance cover in Freedom of Choice even if my account has not received any contributions or other amounts for a continuous 16 month period.

Election to Opt-in for Insurance cover (Employer Members only) *

YesNo

I elect to receive automatic insurance cover even if my account has a balance of less than $6,000 and/or I am under 25 years old.

Declaration

By making this election you are instructing the trustee to keep your insurance cover in place or apply insurance cover to your account. The trustee has not taken into account your particular objectives, financial circumstances or needs. You should consider obtaining personal financial advice that takes into account your particular circumstances before making any financial decisions based on the information provided.