Declaration and acknowledgement

This section must be completed in all circumstances.

I declare that:

• I’ve read the Privacy Collection Statement and I understand how AustralianSuper will use my personal information.
• I’ve read and understood the Important change to your Income Protection notice from AustralianSuper about my basic age-based Income Protection and am using this form to keep it.
• If I’ve provided my email address and/or phone number, I consent to AustralianSuper sending me information about my account, AustralianSuper’s products and services and marketing communications, including third party products and services, via email, my online account, SMS, mobile app or phone, as appropriate and in accordance with AustralianSuper’s Privacy Policy. I understand I can change my communication preferences at any time by calling AustralianSuper on 1300 300 273 or through the Communication preferences section of my account online.

I acknowledge that:

• By completing this form I’m choosing to keep my basic age-based Income Protection. Age-based cover means the amount of cover I get and the cost of it will change as I get older.
• I’ve read the Insurance in your super guide (available at australiansuper.com/InsuranceGuide) and understand the difference between age-based cover and fixed cover.
• If I keep my basic age-based Income Protection, my cover may stop in the future if my account becomes inactive (because I haven’t received any contributions or rollovers into my super account for a continuous period of 16 months). My cover could also stop for several other reasons, as detailed in the When cover stops and how you can get cover again section of the Insurance in your super available at australiansuper.com/InsuranceGuide
• The cost of my cover will continue to be deducted monthly from my super account.
• If limited cover or exclusions applied to my cover previously, these conditions will continue to apply to my cover.
• Insurance cover will only be provided in line with the insurance policy terms and conditions as agreed between AustralianSuper and the Insurer. Those terms and conditions may change from time to time and AustralianSuper will notify me of those changes where required by law.
• My eligibility to claim for benefits will be determined by the Insurer in line with AustralianSuper’s insurance policy terms and conditions.
• Basic age-based Income Protection may be unsuitable if the cover amount for my age is more than 85% of my salary. If I’m eligible to make a claim, I won’t receive the total amount of cover I’m insured for.
• If eligible, Income Protection benefit payments are based on my pre-disability income and other factors. It may be reduced by income I receive from other sources. Up to 75% is paid to me and up to 10% to my AustralianSuper account. My pre-disability income is the before-tax salary I earned from my regular job(s) immediately before I was ill or injured, excluding Super Guarantee (SG) contributions. Salary may be different if I own a business or I’m not an employee.
• If I want to keep my basic age-based Income Protection I must fully complete, sign, date and return this form by 25 March 2024, otherwise my cover will be reduced to $1,000 a month of fixed cover.
• I can cancel, reduce, apply for or increase cover anytime.