1. Healthcare

Apply for Voluntary Insurance Cover
Use this form to apply for Voluntary Death and Terminal Illness and
Total and Permanent Disablement Insurance Cover
Before you start...
Fill this form out in BLOCK letters using a black or blue pen. Write
to mark boxes.
Duty of Disclosure
Non-disclosure
Before you enter into a contract of insurance with an insurer,
you have a duty under the Insurance Contracts Act 1984 (Cth)
to disclose to the insurer every matter that you know, or could
reasonably be expected to know, is relevant to the insurer’s
decision whether to accept the risk of insurance and, if so, on
what terms.
If you don’t disclose to the insurer every matter that you know, or could reasonably be expected
to know, would be relevant to the insurer’s decision whether to accept the risk of the insurance
and if so, on what terms, the insurer may avoid the contract, or avoid your cover within three
years of entering into it, provided the insurer wouldn’t have entered into that contract or
accepted cover for you had full disclosure been made.
You have the same duty to disclose those matters to the
insurer before you renew, extend, vary or reinstate a contract
of insurance. Your duty, however, doesn’t require disclosure of
a matter that:
■■ diminishes the risk to be undertaken by the insurer
■■ is of common knowledge
■■ the insurer knows, or in the ordinary course of business,
ought to know, or
■■ the insurer has waived.
Where the insurer is entitled to avoid a contract of insurance, the insurer may elect not to avoid
it but apply either of the following options:
■■ reduce the sum you would’ve been insured for in accordance with a formula that takes into
account the premium that would’ve been payable if you had disclosed all relevant matters
to the insurer, or
■■ vary the contract in such a way as to place the insurer in a position the insurer would’ve
been had you disclosed all relevant matters or not made a misrepresentation.
Where your contract is in respect to death cover, the insurer may only apply the first of the two
options and the insurer must do so within three years of you entering into the contract or the
insurer providing cover to you.
Member number
1. Your personal details
Mr
Ms Mrs Miss Dr
Other
MaleFemale
Given names
Surname
Date of birth (DD-MM-YYYY)
–
Residential address
Suburb
–
StatePostcode
Postal address. If the same as your residential address, mark ‘ ’ in this box Suburb
Mobile phone
StatePostcode
Home phone
Preferred email
Work phone
Other email
May one of OnePath’s underwriting staff or authorised service providers contact you by phone if they need more information?
No
At which time?
Yes. Which is the most convenient day to call?
From
to
On which phone? M)
(H)
(W)
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Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
APPVOLINS
Page 1 of 23
2. What type of insurance do you want and how much?
■■ The amount you apply for must be a multiple of $10,000.
■■ Don’t include your existing Basic and Voluntary Insurance Cover in this amount
Only mark
in one box
Death and Terminal Illness insurance only
Death and Terminal Illness and Total and Permanent Disablement insurance
Total and Permanent Disablement insurance only. You can only choose this option if you already have Death and Terminal Illness
insurance with us. The amount of Total and Permanent Disablement insurance you apply for can’t be more than your Death and
Terminal Illness insurance.
How much insurance do you want to apply for?
$
,
,
.
3. Residence and travel details
Mark
in the appropriate box
Are you currently residing in Australia?
Yes
No
Yes
No
Yes
No
If no, tell us where you’re currently residing and how long you intend to reside there?
Are you an Australian citizen or do you hold a visa that entitles you to reside permanently in Australia?
If no, tell us what type of visa you hold.
Do you have any intention of travelling outside Australia within the next two years?
If yes, please complete the following:
Date of departure (DD/MM/YYYY)
–
Duration of stay
–
Destinations (country/cities)
Purpose of stay
Holiday
Business
Residing
Other. Please specify
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 2 of 23
4. Your job details
■■ Read the descriptions of the five job classifications carefully, as they’re used to work out how much your insurance costs.
■■ If you’re unemployed, retired or not working, select ‘light manual’.
■■ Your selected job classification will apply to all your insurance with us, even if your application isn’t accepted. Any new
insurance premiums will apply to your total insurance cover, including existing Basic or Voluntary Insurance Cover, from
the date we receive this form once your application is accepted.
Mark ‘ ’ in one box
Heavy manual: You perform heavy manual work or
work in an open-cut mine for more than 20% of your
total work time and spend less than 5% of your work
time in an underground mine. Your occupation mustn’t
be in ‘mining’, as defined below. Types of duties
that may fit within this category: bricklayer, roof
carpenter, truck driver, forklift driver, bulldozer driver.
Professional: You work in a predominantly office based sedentary
occupation for over 80% of your total work time and earn more than
$80,000 pa, excluding employer super contributions.
White collar: You work in a predominantly office based sedentary
occupation for over 80% of your total work time.
Professional and white collar only. Regardless if you mark the
professional or white collar job classification, you’ll be considered white
collar if your salary is $80,000 pa or less and professional if your salary
is over $80,000 pa, excluding any employer super contributions.
Mining: You perform light or heavy manual work and
are required to work in an underground mine for
more than 5% of your total work time.
Light manual: You perform light manual work for more than 20% of
your total work time and spend less than 5% of your work time in an
underground mine, so long as your occupation isn’t defined as ‘heavy
manual’ or ‘mining’.Types of duties that may fit within this category:
carpenter, electrician, plumber, factory production manager.
Regardless of your occupation, if you spend more
than 20% of your time in an open cut mine you’ll
be classified as ‘heavy manual’ and if you spend
more than 5% in an underground mine you’ll be
classified as ‘mining’.
Have you joined any armed forces other than the Australian Armed Forces Reserves?
Yes
No.
What is your usual occupation?
Describe all your present duties in the table below. Complete both the percentage of time and specific duties in all cases.
Type of work
% time
Describe specific duties and where they’re performed
Sedentary/administration eg filing, computer work,
answering phone, reception duties etc
Manual work – light eg driving, warehousing, surveying
lifting under 5kg etc
Manual work – heavy eg bricklaying, lifting over 5kg,
painting, carpentry, mechanic etc
How many hours, on average, do you work per week?
hours per week
What’s your current annual income earned through personal exertion, before-tax and
including super contributions, but after deduction of business expenses? $
Do you have more than one occupation?
,
.
pa
Yes No
If ‘yes’, please specify the occupation, your normal duties and the average hours you work per week in each of your other occupations.
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Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 3 of 23
5. Personal statement
1. What is your current height and weight?
Height (cm) Weight (kg)
2. During the last 12 months have you smoked tobacco or any other substance?
Yes
No
Yes
No
Yes
No
Yes
No
If yes, state type and quantity per day.
3. During the last three months, have you used nicotine replacement therapy eg nicotine gum, patches etc or
anti-smoking medication eg Zyban, Chantix etc?
If yes, state type and quantity per day. If you need more space go to page 23.
4. Have you ever been advised to stop smoking due to a medical condition?
If yes, complete all the questions in all the sections of this form, except Part A
5. Do you consume alcohol?
If yes, state the type and how many standard drinks you consume per day. A standard drink is 125ml wine, 250ml beer or 30ml spirits. If you
need more space go to page 23.
6. Have you ever been advised to stop or reduce your alcohol intake due to a medical condition?
Yes
No
If yes, complete all the questions in all the sections of this form except for Part A.
Only answer questions 7 and 8 of this section if you:
■■ answered ‘yes’ to questions 4 and/or 6 of this section
■■ are age 54 or under and applying for more than $1 million in Death and Terminal Illness and Total and Permanent
Disablement insurance
■■ are age 55 or over and applying for more than $750,000 in Death and Terminal Illness and Total and Permanent
Disablement insurance
7. Has your weight varied by more than 10 kg during the last 12 months (excluding pregnancy)?
Yes
No
Yes
No
If yes, provide details.
8. Non-smokers – have you ever smoked regularly in the past?
If yes, state type, quantity per day and date ceased.
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 4 of 23
Part A - medical history
Complete Part A of this form if you:
■■ are age 54 or under and applying for less than $1million in Death and Terminal Illness and Total and Permanent
Disablement insurance
■■ are age 55 or over and applying for up to $750,000 in Death and Terminal Illness and Total and Permanent
Disablement insurance
■■ answered ‘no’ to questions 4 and 6 of section 5 Personal statement.
Mark ‘ ’ in one box
Are you, at the date of this application, off work due to injury or illness or restricted from performing any of the usual
duties of your occupation due to injury or illness (other than for colds or flu)?
Yes
No
Yes
No
Yes
No
High blood pressure, high cholesterol, heart complaint, murmur, palpitations or chest pain, stroke, diabetes,
thyroid or glandular disorder, cancer, tumour or growth including breast lumps or skin lesions/moles, even if
you haven’t seen a doctor?
Yes
No
Back or neck pain/disorder, musculo-skeletal symptoms or any joint disorder, gout, arthritis, repetitive strain
syndrome, paralysis of any kind or chronic fatigue syndrome, epilepsy or neurological disorder,
mental/nervous disorder, including stress, anxiety or depression?
Yes
No
Kidney, bowel, bladder, gall bladder, liver disease or disorder, hepatitis, hernia, blood disorder, sleep apnoea,
asthma, persistent cough or any lung complaint, any abnormality of hearing, speech or eyesight, excluding
glasses or contact lenses?
Yes
No
Have you ever tested positive for Human Immunodeficiency Virus (HIV), which causes Acquired Immune
Deficiency Syndrome (AIDS), or are you suffering from AIDS or any AIDS related conditions?
Yes
No
Are you currently receiving any form of medical treatment or taking any form of medication (other than for cold or flu)?
Have you taken more than a total of seven consecutive days off work in the past 12 months due to illness or injury
(other than for cold or flu)?
Have you ever received medical advice, consulted a doctor, undergone medical treatment, investigations or operations
for, or suffered from any of the following.
If you answered ‘yes’ to any of the questions above in Part A, you’ll need to complete Part B of this form.
6. Your declaration (you must sign and date this section)
AUSCOAL Super and the insurer may verify the information you’ve
provided and ask for more information.
I declare that:
■■ I’ve read the duty of disclosure and I’m aware of the
consequences of non-disclosure. I understand that in connection
with my insurance application, I must advise AUSCOAL Super
and OnePath Life Limited ABN 33 009 657 176 AFSL 238 341
(OnePath Life) of any changes in my health from now until I’m
notified in writing that my application has been accepted. I’ve
disclosed everything I know that could affect the decision to
accept my application
■■ the answers I’ve provided to all questions and the declarations
are true and correct
■■ I understand my insurance cover won’t become effective until my
application has been accepted in writing and provided my member
account has adequate funds to meet the premium payable
■■ I acknowledge that if I don’t complete this form correctly or I
don’t sign and date this declaration, my application won’t be
considered and any insurance cover I currently have won’t be
affected. I’ve read and understood the AUSCOAL Super Product
Disclosure Statement, including the Insurance Guide
■■ I consent to the collection, use and disclosure of my personal
information in accordance with the AUSCOAL Super privacy policy
outlined in the AUSCOAL Super Product Disclosure Statement
(PDS) and OnePath Life’s privacy policy available at www.onepath.
com.au/ aboutOnePath/privacy-policy.aspx
■■ I understand that if my application for cover is accepted, insurance
cover will be provided to me on the terms contained in AUSCOAL
Super’s insurance policy with OnePath Life as changed from time
to time
■■ I understand AUSCOAL Super and OnePath Life may require
additional information or medical tests to enable assessment of my
application and I authorise any medical practitioner or other health
professional to release to AUSCOAL Super and OnePath Life or any
other organisation appointed by AUSCOAL Super or OnePath Life
any medical information needed in connection with my application
■■ I understand that if I fail to attend any required medical
appointments, my application may not be finalised and insurance
cover may not be offered by OnePath Life.
Your signature
Date (DD-MM-YYYY)
–
–
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 5 of 23
Part B - full personal statement
Complete all the sections of Part B if you:
■■ are age 54 or under and applying for more than $1 million in Death and Terminal Illness and Total and Permanent
Disablement insurance
■■ are age 55 or over and applying for more than $750,000 in Death and Terminal Illness and Total and Permanent
Disablement insurance
■■ answered ‘yes’ to any ‘Medical history’ questions in Part A.
■■ answered ‘yes’ to questions 4 and/or 6 in section 5. Personal statement on page 4.
If you need more space to write your answers, use page 23.
1. Pastimes
Have you any intention of engaging in:
Mark ‘ ’ in one box
1. motorcycle/motor racing, other than as a means of transportation to and from work?
Yes
No
2. any hazardous activities or sports eg motor or water sports, such as canoeing; football; parachuting; recreations
involving heights; underwater sports; caving; body contact sports; gliding; hang gliding etc?
Yes
No
3. aviation/flying, other than as a fare-paying passenger?
Yes
No
If you answered yes to any of questions 1, 2 or 3, continue completing this section for the relevant activity.
Motorcycle/motor racing
Vehicle type
Races per year
Class:
Recreational
Scuba/skin diving
Average depth (m)
Amateur
Maximum depth (m)
Engine size
Max. speed (km/h)
Professional
Dives per annum
Do you use explosives?
Yes
No
Yes
No
Yes
No
If yes, provide details.
Do you dive in caves or potholes?
If yes, provide details.
Football, soccer, Aussie Rules etc
Code played and grade
Games per year
Do you receive any income participating in football/soccer/Aussie Rules etc?
If yes, provide amount and details.
Class:
Recreational
Amateur
Professional
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Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 6 of 23
1. Pastimes...continued
Aviation/flying
Do you hold a Civil Aviation Safety Authority (CASA) licence?
Yes
No
Yes
No
Yes
No
Yes
No
If yes, state type and period held.
Do you intend to change the scope of your present licence?
Have you ever had an accident or been charged with violating CASA regulations?
Do you always use authorised landing areas?
Complete the table below
Past 12 months
Number of hours flown
Crew
Passenger
Future annual average
Crew
Passenger
Commercial airline
Charter
Private
Aero club/flying school
Agriculture
Helicopter
Ultralight aircraft
Do you intend to engage in any form of aviation other than the above categories eg ballooning, aerobatics,
parachuting, paragliding?
Yes
No
If yes, provide frequency and details.
Other sports or pastimes
Provide details and frequency of any other hazardous activities or sports you participate in eg boxing, competitive riding, mountain
climbing, body contact sports, caving, etc.
On what basis do you partake in this activity?
Recreational
Amateur
Professional
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 7 of 23
2. Insurance details
Are you covered by, or are you applying for, any other life, Total and Permanent Disablement, trauma, income
protection, salary continuance or living expense cover with any company, including OnePath Life (other than this
application), and income protection held through the Fund, including benefits under superannuation or insurance
benefits by your employer?
If yes, tell us which insurances and provide details of the date the policy was last fully underwritten.
Name of company
Type of cover
Amount
insured
Date
commenced
(DD/MM/YYYY)
Will this policy be
discontinued or
replaced?
Yes
No
Date last fully
underwritten
(replacement policies only)
(DD/MM/YYYY)
$
/
/
Yes
No
/
/
$
/
/
Yes
No
/
/
$
/
/
Yes
No
/
/
$
/
/
Yes
No
/
/
Have you ever had an application for insurance on your life declined, deferred, accepted with a higher than normal
premium or issued with restrictions or exclusions?
Yes
No
Yes
No
If yes, tell us the name of the company, alteration, date and reason (if known).
Have you ever made a claim for or received sickness, accident or disability benefits, Veterans Affairs benefits, workers
compensation, unemployment benefits or any other form of compensation?
If yes, tell us when, amount, period paid, type of disability suffered, date claim finalised etc
3. Family history
■■ You’re only required to disclose family history information pertaining to first degree blood related family members - living or
deceased eg mother, father, brothers, sisters.
■■ If you’re adopted and your family history is unknown, please state so.
Have any of your parents, brothers or sisters (alive or deceased) suffered from Huntington’s disease, muscular
dystrophy, multiple sclerosis, cystic fibrosis, familial adenomatous polyposis of the bowel, polycystic kidney disease,
Alzheimer’s disease, dementia or any other hereditary or familial disorder?
Have any of your parents, brothers or sisters (alive or deceased) prior to age 60 been diagnosed with diabetes,
heart disease, mental illness, haemophilia, haemochromatosis, high blood pressure, high cholesterol, breast cancer,
cervical cancer, bowel cancer or any other cancer (please specify type), stroke or kidney disease?
Mark ‘ ’ in one box
Yes
No
Yes
No
If you answered yes to either of the above two questions, complete the following table.
Relation
Condition/disorder
Age diagnosed
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Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 8 of 23
4. Medical history
To the best of your knowledge, have you ever had any of the following?
Mark ‘ ’ for either yes or no and circle the specific conditions that apply to you
1
Asthma
Yes
No
2
High blood pressure
Yes
No
3
High cholesterol
Yes
No
4
Diabetes
Yes
No
5
Stress, anxiety, depression or any other mental health condition
Yes
No
6
Back or neck pain, sciatica or any disorder of the spine or neck
Yes
No
7
Arthritis, shoulder or knee pain or any other disorder of the joints
Yes
No
8
Cyst, mole or skin lesion
Yes
No
If you answered ‘yes’ to any of the conditions above, complete the relevant questionnaire on pages 14 to 22
9
Sleep apnoea, bronchitis, persistent cough or any other chest or lung condition
Yes
No
10
Heart condition, murmur, chest pain, rheumatic fever, palpitations, stroke or vascular disorder
Yes
No
11
Thyroid or glandular trouble
Yes
No
12
Ulcers, bowel trouble or recurring indigestion
Yes
No
13
Epilepsy, fits or dizziness, fainting of any kind or persistent headaches
Yes
No
14
Alzheimer’s disease or dementia
Yes
No
15
Kidney, liver, prostate or bladder problems, renal colic or stones, nephritis, lupus nephritis, pyelitis or cystitis
Yes
No
16
Broken bones, osteoporosis or any pain, strain or disorder of any muscles, ligaments, cartilage or limbs
Yes
No
17
Gout, fibromyalgia, tendonitis, tenosynovitis, RSI, or any regional pain syndrome, chronic fatigue syndrome
(myalgic encephalomyelitis)
Yes
No
18
Cancer, tumour, growths of any kind or breast lumps, even if you haven’t seen a doctor
Yes
No
19
Varicose veins, hernia, scleroderma, systemic sclerosis or skin disorders
Yes
No
20
Any abnormality affecting eyesight, hearing or speech
Yes
No
21
Any abnormality affecting physical mobility or muscular power eg multiple sclerosis or any diagnosed intellectual
disability or cognitive impairment
Yes
No
22
Anaemia, haemophilia or any other disease of the blood
Yes
No
23
Bowel, liver or gall bladder disease or hepatitis
Yes
No
24
Coughing of blood or passing of blood from the bowel or in the urine
Yes
No
25
Have you, within the last five years, had any other illness, injury, operation, x-ray, electrocardiogram, blood
transfusion, any other special tests or been advised to have a blood test for any reason?
Yes
No
26
Due to injury or illness, have you ever been off work for more than seven consecutive days, if not
already mentioned?
Yes
No
27
Do you now have any symptoms of ill health or disability?
Yes
No
28
Are you contemplating surgery, intending to consult a doctor, or have you been advised to have an operation or
other medical investigation or test in the future eg x-ray, ECG, blood test etc?
Yes
No
29
Have you ever had or are you considering having a genetic test where you received or are currently awaiting an
individual result?
Yes
No
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 9 of 23
30
Do you take, or have you ever taken, drugs or any medications on a regular or ongoing basis?
Yes
No
31
Have you ever used or injected any drugs not prescribed for you by a medical attendant or have you ever
received advice, counselling or treatment for drug dependence?
Yes
No
32
The following questions are for females only. If you’re a male, go to question 33
Yes
No
Yes
No
■■ Have you ever had an abnormal cervical smear test (pap), breast ultrasound or mammogram?
Yes
No
■■ Have you ever had any symptoms of, or sought advice or treatment for, any condition of the cervix, ovary,
uterus, breast or endometrium?
Yes
No
33
Are you suffering from unintentional weight loss, persistent night sweats, persistent fever, diarrhoea or
swollen glands?
Yes
No
34
Have you ever tested positive for Human Immunodeficiency Virus (HIV), which causes Acquired Immune
Deficiency Syndrome (AIDS), or are you suffering from AIDS or any AIDS related condition?
Yes
No
35
Have you received or are you expected to receive treatment, or undergo a medical consultation, for a sexually
transmitted disease, including, but not limited to, HIV (AIDS), gonorrhoea or syphilis?
Yes
No
36
In the past five years, have you had:
■■ sex without using a condom with a person you know or suspect to be either HIV positive or who uses nonprescribed drugs intravenously
Yes
No
■■ sex without using a condom with a sex worker or as a sex worker
Yes
No
■■ anal intercourse without using a condom, except with someone whom you’ve been in a monogamous
relationship for five years or more?
Yes
No
■■ Have you ever had any complications with pregnancy or childbirth?
■■ Are you pregnant now? If yes, what’s your advised due date? (DD/MM/YYYY)
/
/
Supplementary questionnaires
If you answered ‘yes’ to any of the questions 1 to 8 in Section 4: Medical history
complete the relevant supplementary questionnaires to provide more details about your condition
If you answered yes to question 1 - Asthma ............................................................................................... go to page 14
If you answered yes to question 2 - Blood pressure ................................................................................... go to page 15
If you answered yes to question 3 - Cholesterol ......................................................................................... go to page 16
If you answered yes to question 4 - Diabetes ............................................................................................. go to page 17
If you answered yes to question 5 - Mental health ..................................................................................... go to page 18
If you answered yes to question 6 - Back / neck ........................................................................................ go to page 20
If you answered yes to question 7 - Arthritis / joint ..................................................................................... go to page 21
If you answered yes to question 8 - Cyst / mole / skin lesion ..................................................................... go to page 22
If you answered ‘yes’ to question 36, a private and confidential questionnaire will be sent to you.
If you answered ‘yes’ to any questions from 9 to 35, complete the tables on the next page.
If there isn’t enough space provide details on page 23.
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 10 of 23
Question number
Disability, illness, injury or condition
Investigation types and results
–
Date of first symptoms (DD-MM-YYYY)
–
Frequency of symptoms
Type of treatment
Date treatment provided and ceased (DD-MM-YYYY)
From
–
–
–
to
Has further treatment, referral or investigations been recommended?
Yes
–
No
Time off work
Have you completely recovered?
Yes
–
No Date of last symptoms (DD-MM-YYYY)
–
Name and address of medical facility and attending doctor
Question number
Disability, illness, injury or condition
Investigation types and results
–
Date of first symptoms (DD-MM-YYYY)
–
Frequency of symptoms
Type of treatment
Date treatment provided and ceased (DD-MM-YYYY)
From
–
–
to
Has further treatment, referral or investigations been recommended?
–
Yes
–
No
Time off work
Have you completely recovered?
Yes
No Date of last symptoms (DD-MM-YYYY)
–
–
Name and address of medical facility and attending doctor
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 11 of 23
Question number
Disability, illness, injury or condition
Investigation types and results
–
Date of first symptoms (DD-MM-YYYY)
–
Frequency of symptoms
Type of treatment
Date treatment provided and ceased (DD-MM-YYYY)
–
From
–
–
to
Has further treatment, referral or investigations been recommended?
Yes
–
No
Time off work
Have you completely recovered?
Yes
–
No Date of last symptoms (DD-MM-YYYY)
–
Name and address of medical facility and attending doctor
5. Usual doctor or medical centre
Full name of doctor or medical centre
Number and street address
Suburb
StatePostcode
PhoneFax
How many years have you been attending this doctor or medical centre?
When was your last visit
to this doctor or medical
centre?
Reason for check up or consultation
years
months
Outcome, including medication,
treatment etc
Degree of
recovery?
%
Have you had any consultations with your usual doctor or another doctor (other than for colds or flu) in the last three years not already mentioned?
No
Yes. Provide details below.
Name, address and phone number of
doctor or medical centre
Date last
consulted
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
Reason for check-up or consultation
Outcome, including degree
of recovery, medication,
treatment etc
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 12 of 23
6. Doctor’s authorisation - to be completed and signed by the life insured
Personal details of life insured
Given names
Surname
Date of birth (DD-MM-YYYY)
–
Residential address
Suburb
–
StatePostcode
Member number
Authortiy to release information
To doctor (name of doctor)
I hereby authorise you to release details of my personal medical history to AUSCOAL Superannuation Pty Ltd ABN 70 003 566 989 and
OnePath Life Limited ABN 33 009 657 176 AFSL 238341, or any organisation duly appointed by AUSCOAL Super or OnePath Life. A
photocopy (or similar) of this authorisation shall be as valid as the original.
Signature of life insured
Date (DD-MM-YYYY)
–
–
Authortiy to release information
To doctor (name of doctor)
I hereby authorise you to release details of my personal medical history to AUSCOAL Superannuation Pty Ltd ABN 70 003 566 989 and
OnePath Life Limited ABN 33 009 657 176 AFSL 238341, or any organisation duly appointed by AUSCOAL Super or OnePath Life. A
photocopy (or similar) of this authorisation shall be as valid as the original.
Signature of life insured
Date (DD-MM-YYYY)
–
–
Before submitting this form, remember to sign Your declaration on page 5
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 13 of 23
Asthma questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 1 on page 9 - Section 4: Medical history
–
–
When did you have your first episode of asthma? (dd/mm/yyyy)
When was your most recent episode of asthma? (dd/mm/yyyy)
–
–
Approximately how many episodes have occurred in the last 12 months? Have you had any time off work due to this condition?
No
Yes, provide the dates and duration
Are the symptoms/attacks typically precipitated by anything in particular eg seasonal, exercise induced, a cold or bronchitis?
No
Yes, provide details
Have you sought medical treatment or advice for asthma?
No
Yes, provide details.
Name of doctor / health professional
Address
Suburb
State
Postcode
Date of last consultation (dd/mm/yyyy)
–
–
How has your doctor described your asthma?
Mild
Moderate
Severe
Have you ever used any medication, including steroids?
No
Yes, provide details below.
Date commenced
Type
(dd/mm/yyyy)
Frequency eg
daily, weekly
Dosage
Date ceased
(if applicable)
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Reason for cessation
Have you ever been hospitalised due to asthma?
No
Yes, provide details.
Date (dd/mm/yyyy) from
/
/
to
/
/
Name of hospital
Address of hospital
Have you ever had lung function tests performed?
No
Yes, provide details.
Date
(dd/mm/yyyy)
/
/
/
/
/
/
Test results
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 14 of 23
Blood pressure questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 2 on page 9 - Section 4: Medical history
When was your high blood pressure first diagnosed?
(dd/mm/yyyy)
What was your blood pressure reading at that time?
Systolic
–
–
Diastolic
Have you ever been treated by medication?
No
Yes, provide details.
Date
commenced
Type
Frequency
eg daily,
weekly
(dd/mm/yyyy)
Dosage
Date ceased
(if applicable)
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Reason for cessation
Did you undergo any tests or investigations?
No
Yes, provide details.
Date
Tests performed
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
Test results
Is the treating doctor different to your usual doctor?
No
Yes, provide details.
Name
Address
Suburb
State
–
–
Date of last consultation? (dd/mm/yyyy)
What was the date of your last blood pressure check? (dd/mm/yyyy)
What was your blood pressure reading at that time?
Postcode
–
–
Systolic
Diastolic
How has your doctor described your blood pressure control?
Excellent
Good
Poor
Other, provide details.
What is the date of your next blood pressure check-up? (dd/mm/yyyy)
–
–
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 15 of 23
Cholesterol questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 3 on page 9 - Section 4: Medical history
–
When was your high cholesterol first diagnosed? (dd/mm/yyyy)
What were your cholesterol readings at that time?
Cholesterol
Triglycerides
–
HDL Cholesterol
LDL Cholesterol
Did you undergo any tests or investigations?
No
Yes, provide details.
Date
Tests performed
Reason for cessation
(dd/mm/yyyy)
/
/
/
/
/
/
Have you ever used any medication?
No
Yes, provide details.
Date
commenced
Type
(dd/mm/yyyy)
Frequency
eg daily,
weekly
Dosage
Date ceased
(if applicable)
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Reason for cessation
Has this treatment ever changed eg has the type or dosage of your medication been changed?
No
Yes, provide details. Date treatment changed
–
–
Reason for change
Is the treating doctor different to your usual doctor?
No
Yes, provide details.
Name
Address
Suburb
State
Date of last consultation? (dd/mm/yyyy)
What was the date of your last cholesterol check? (dd/mm/yyyy)
What were your cholesterol readings at that time?
Cholesterol
Triglycerides
–
–
Postcode
–
–
HDL Cholesterol
LDL Cholesterol
How has your doctor described your cholesterol control?
Excellent
Good
Poor
Other, provide details.
What is the date of your next cholesterol check-up? (dd/mm/yyyy)
–
–
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 16 of 23
Diabetes questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 4 on page 9 - Section 4: Medical history
–
When was your diabetes first diagnosed? (dd/mm/yyyy)
How is your diabetes controlled?
–
Insulin. How many times a day do you administer insulin?
I’m on an insulin pump.
One or two times daily.
Three or more times daily.
Diet only. How often do you monitor your sugar levels?
One or two times daily.
Three or more times daily.
Other, provide details.
Oral. How often do you monitor your sugar levels?
One or two times daily.
Three or more times daily.
Other, provide details.
List your medications below.
Have you ever had insulin reactions, diabetic coma, heart, kidney, peripheral vascular disease or eye problems (not already mentioned in
the Personal Statement), or protein in the urine?
No
Yes, provide details.
Date
Condition
(dd/mm/yyyy)
/
/
/
/
Treatment
Have you had a glycosylated haemoglobin (HbA1c) test in the last six months?
No
Yes, provide details.
Date
(dd/mm/yyyy)
/
/
/
/
Test results
Is this result consistent with others taken over the last 12 months?
Yes
No, provide details.
Date
(dd/mm/yyyy)
/
/
/
/
Test results
Is the treating doctor different to your usual doctor?
No
Yes, provide details.
Name of doctor
Address
Suburb
Date of last consultation (dd/mm/yyyy)
State
–
Postcode
–
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 17 of 23
Mental health questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 5 on page 9 - Section 4: Medical history
Please tick the conditions you’ve had, currently have or received treatment for.
Anxiety, including generalised anxiety, panic or phobia disorder
Eating disorder, including anorexia nervosa or bulimia
Depression, including major depression or dysthymia
Manic depressive illness or bi-polar disorder
Alcohol or other substance abuse or addiction
Post traumatic stress
Schizophrenia or any other psychotic disorder
Stress, sleeplessness or chronic tiredness
Other, please describe
Complete the table below for all described conditions.
Condition
Describe your symptoms
Have you ever had any recurrence of the symptoms?
Are you currently symptom free?
No
Have you ever attempted suicide or self harm?
No
Date
diagnosed
(dd/mm/yyyy)
Date condition
ceased (if applicable)
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Yes, provide details, including dates.
Yes, provide date(s) of last symptoms.
No
Yes, provide details, including when, name and address of treating doctor,
clinic or hospital.
Are you aware of the cause or reason for your condition(s)?
Have you ever had any time off work due to your condition(s)?
No
Yes, provide details.
No
Yes, provide dates and duration.
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 18 of 23
Mental health questionnaire continued...
Continued from previous page
Are you currently or have you ever been on treatment, including medication?
Treatment
(eg tranquillisers, sedatives, ECT, counselling, etc)
Date
commenced
No
Date ceased
(if applicable)
(dd/mm/yyyy)
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Yes, provide details.
Reason ceased
Do you feel your condition(s) has had any impact on your ability to perform your job at work or on your social life?
No
Yes, provide details.
Have you been referred for consultation with a psychiatrist or psychologist?
No
Yes, provide details.
Name of consultant
Address
Suburb
Date of last consultation (dd/mm/yyyy)
Have you been admitted to hospital or any other care facility?
State
–
No
Postcode
–
Yes, provide details.
Name of institution
Address
Suburb
Date of last consultation (dd/mm/yyyy)
State
–
Postcode
–
Doctor(s) consulted
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 19 of 23
Back / neck questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 6 on page 9 - Section 4: Medical history
–
When did your back / neck condition first occur? (dd/mm/yyyy)
Which area(s) of your back/neck was affected eg middle back?
–
What was the cause or reason for the condition?
Describe the exact nature of the condition, including symptoms and doctor’s diagnosis if known eg sciatica, prolapsed disc, whiplash etc
Was an x-ray, CT scan or any other type of investigation performed?
No
Date
Tests
Results
(dd/mm/yyyy)
/
/
/
/
Yes, provide details.
Have you had recurrent or multiple episodes of the back/neck condition?
No
Yes, provide details, including number of episodes and date of the most recent episode, including duration.
Provide details of all people you’ve consulted for this condition.
Type
Name and address of doctor /health professional
Date last
consulted
eg doctor,
chiropractor,
physiotherapist
Treatment prescribed
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
eg analgesics, anti-inflammatory drugs,
immobilisation
Have you had any time off work due to this condition?
No
Yes, provide dates and duration.
Are your work duties or activities limited / affected by the condition?
No
Yes, provide dates and duration.
Are you still undergoing treatment or do you have any residual pain, limitation of movement or restriction of any kind?
No
Yes, provide dates and duration.
Overall, do you feel your back / neck condition is:
Resolved
Improving
Stable
Deteriorating
What was the date of your last symptoms? (dd/mm/yyyy)
–
–
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 20 of 23
Arthritis / joint questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 7 on page 9 - Section 4: Medical history
Which joint is/was affected? Tick the relevant boxes. If you tick more than one box copy this questionnaire and complete for each condition.
Left
Ankle
Elbow
Shoulder
Knee
Right
Left
Wrist
Right
Hip
Other
–
When did this condition first occur? (dd/mm/yyyy)
What was the cause or reason for the condition?
which joint?
–
Describe the exact nature of the condition, including symptoms and doctor’s diagnosis if known.
Have you had recurrent or multiple episodes of the condition?
No
Yes, provide details, including the number of episodes and date of the most recent episode, including duration.
Provide details of all people you’ve consulted for this condition in the table below.
Name and address of doctor/
health professional
Type
eg doctor, chiropractor, physiotherapist
Date last
consulted
(dd/mm/yyyy)
/
/
/
/
/
/
Treatment prescribed
eg steroids, anti-inflammatory drugs, surgery,
acupuncture
Have you had any time off work due to this condition?
No
Yes, provide dates and duration
Do you have any residual pain, limitation of movement or restriction of any kind?
No
Yes, provide details
Are your work duties or activities limited/affected by the condition?
No
Yes, provide details
Are you still undergoing treatment?
No
Yes, provide details
Overall, do you feel your condition is:
Resolved
Improving
Stable
Deteriorating
What was the date of your last symptoms? (dd/mm/yyyy)
–
–
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 21 of 23
Cyst / mole / skin lesion questionnaire
Only complete this questionnaire if you answered ‘yes’ to question 8 on page 9 - Section 4: Medical history
Provide details in the table.
Date
diagnosed
Site
eg back, left leg
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
Type
eg basal cell carcinoma, melanoma, cyst,
mole
Pathology results
eg malignant, benign, unknown
Was the cyst/mole/skin lesion(s) removed?
No, provide details, including date set for removal, if applicable.
Yes, date of removal
(dd/mm/yyyy)
–
–
Provide details for each. By what method eg surgically, frozen or burnt off?
Have you been or are you required to attend any further treatment or regular follow up since the original removal?
No
Yes, provide details and advise how often follow up is required.
Have you had any other tests, investigations or treatments not mentioned above?
No
Yes, provide details.
Tests/treatments/investigations
Date
(dd/mm/yyyy)
/
/
/
/
/
/
/
/
Results
Is the treating doctor different to your usual doctor?
No
Yes, provide details.
Name of doctor
Address
Suburb
Date of last consultation (dd/mm/yyyy)
State
–
Postcode
–
Go to the next page to continue filling out this form...
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 22 of 23
Additional information or comments
When complete return this form to us by:
Mail: AUSCOAL Super, Locked Bag 1, Warners Bay NSW 2282
Fax: 02 4948 6955
Email: [email protected]
Call: 1300 AUSCOAL (1300 287 262) Email: [email protected] Web: www.auscoalsuper.com.au
AUSCOAL Superannuation Fund ABN 16 457 520 308 Trustee: AUSCOAL Superannuation Pty Ltd
ABN 70 003 566 989 AFSL 246864 MySuper authorisation 16457520308485 | 10-01-023_can140738
Page 23 of 23