Where would you like the certificate returned to and who should be contacted if there are any queries:

Name:
Company:
Address:
Phone:
Fax:
Email:

Fund Identification Details

Please ensure the name of the fund is exactly as set out in the trust deed e.g. Superannuation Fund not Super Fund, etc. The names of individual trustees should be in full, no initials. If the trustee is a company please include ACN/ABN number.

Name of Fund:
Full Names of Trustees:
Address of Trustees:
Date Fund Established:
Financial Year:
Part Year Coverage:	Yes     No
If part year - Start Date:
Reserve Amount at Start:

	Member 1	Member 2	Member 3	Member 4
Name:
Age Next Birthday:
Sex:	Male  Female	Male  Female	Male  Female	Male  Female
Smoker:	Yes    No	Yes    No	Yes    No	Yes    No
Occupation:

Type of Covers for Death/Death & TPD (Max Benefit of any one cover = Reserve)

	Member 1	Member 2	Member 3	Member 4
	No Cover Death Only Death & TPD	No Cover Death Only Death & TPD	No Cover Death Only Death & TPD	No Cover Death Only Death & TPD
Cover Amount:

Salary Continuance (Max monthly amount lesser of 1/24th of Reserve or 75% of Salary)

	Member 1	Member 2	Member 3	Member 4
	No Cover 2 yr - 30 day wait 2 yr - 90 day wait	No Cover 2 yr - 30 day wait 2 yr - 90 day wait	No Cover 2 yr - 30 day wait 2 yr - 90 day wait	No Cover 2 yr - 30 day wait 2 yr - 90 day wait
Cover Amount:

Comments:

type any extra comments here  

Note: You may wish to print this page for your own records before you hit the submit button.

Actuarial Fees

Complying Pensions: $132.00 plus $66 for each additional pensioner (inclusive of GST)
Invoices will be forwarded with certificate.

Return to Superannuation page.