BT Protection Plans Ongoing Partial Rollover Request

1 Perforate PerforatePage 1 of 2 BTF33169 0420vxGPO Box 5467, Sydney NSW 2001, Australia Telephone 1300 553 764 Facsimile (02) 9274 5239 Email Funds Management Limited ABN 63 002 916 458 AFSL 233724 Retirement WrapABN 39 827 542 991, RSE R1001327By completing this form, you consent to the Rollover or transfer of part of the superannuation benefits from your nominated superannuation account to Retirement Wrap to occur each year on or after the policy renewal date for the annual premium amount on your Term Life as Superannuation and/or Income Protection as Superannuation insurance policy(ies).

2 When completing this form:Print clearly in BLOCK LETTERSPERSONAL DETAILST itleMr Mrs Miss Ms Dr Other (please specify)Full nameOther/Previous namesDate of birth (dd/mm/yyyy)//GenderMale Female Home Phone Number( )Work Phone Number( )MobileEmail AddressFUND DETAILSP lease provide the details of your superannuation fund and account from which Partial rollovers or transfers will be made to Retirement Wrap on an Ongoing FundFund nameUnique Superannuation Identifier (USI)Fund phone numberAustralian Business Number (ABN)Account/Member numberRetirement Wrap will Request the exact amount applicable to maintain insurance premium payments for the cover held in your Term Life as Superannuation and/or Income Protection as Superannuation insurance policy(ies).

3 You should ensure your account has sufficient funds available when each Rollover or transfer is due to pay for the applicable premium and costs required for your Term Life as Superannuation and/or Income Protection as Superannuation policy, as well as continuing to meet the minimum balance requirements of your transferring fund (if applicable).POLICY DETAILSP lease indicate the Term Life as Superannuation and/or Income Protection as Superannuation insurance policy(ies) to which this Ongoing Partial Rollover Request 1 Policy 2 Policy 3BT Protection PlansOngoing Partial Rollover RequestPerforate PerforatePage 2 of 2 BTF33169 0420vxAUTHORISATION AND DECLARATIONBy signing this Request form I am making the following statements.

4 I declare that I am the account holder, and I am authorising this Request , and the information provided in this form is true and correct. I Request and consent to the rollovers or transfers of superannuation benefits as described above and authorise the superannuation provider of each fund to give effect, at each policy renewal, to the Rollover or transfer of the annual amount required to maintain the Retirement Wrap policy(ies) listed above or if the policy(ies) are not listed above, I authorise the Superannuation provider to insert the policy number(s) on this form at a later stage. I authorise the trustee of Retirement Wrap to Request the Rollover or transfer of funds, for the amount required to meet premiums due in respect of my Term Life as Superannuation and/or Income Protection as Superannuation insurance policy(ies), and for my existing fund to provide information to the Trustee of Retirement Wrap on Request regarding this Rollover Request , on my behalf until such time that I Request , in writing, to cancel this authority, submit a new Ongoing Partial Rollover Request , or my insured benefits cease.

5 Where this Ongoing Partial Rollover Request has been completed for multiple policies, I authorise the trustee of Retirement Wrap to allocate the Rollover funds received between these policies as required. I acknowledge this authority allows for multiple rollovers to be requested as required for the purposes of paying insurance premiums and will remain effective until this Ongoing authority ceases. I give the transferring fund named in this form, the authority to provide any and all relevant information to the trustee of the Retirement Wrap to facilitate the requested Rollover . I authorise the trustee of the Retirement Wrap and its administrator to provide my tax file number and any other information to my transferring fund, as required to give effect to these transfers. I discharge the transferring superannuation fund named in this form of all further liability in respect of the benefits transferred to Retirement Wrap.

6 I am aware I may ask the transferring superannuation fund for information about any fees or charges that may apply, or any other information about the effect these rollovers or transfers may have on my benefits, and have obtained or do not require such information. I understand that transfer fees and/or exit fees or penalties may apply as a result of these rollovers and I authorise the deduction of those fees. I acknowledge that it is my responsibility to ensure that the account balance of the account with my nominated superannuation fund is sufficient to allow for the Rollover of the required amount as and when it becomes due, and to ensure that the account will continue to meet any minimum balance requirements of the transferring (Print in BLOCK LETTERS)SignatureDate (DD/MM/YYYY)/ /After completing this form: Sign the authorisation Send the Request to us by: mail BT GPO Box 5467 Sydney NSW 2001.

7 Fax (02) 9274 5763 email Term Life as Superannuation (USI 39 827 542 991 003) and Income Protection as Superannuation (USI 39 827 542 991 004) are part of Retirement Wrap ABN 39 827 542 991, RSE Registration R1001327, which is a complying fund constituted under the Retirement Wrap Trust Funds Management Limited ABN 63 002 916 458, AFSL 233724 is the trustee of BT Term Life as Superannuation and Income Protection as Superannuation. The Trustee s Registrable Superannuation Entity (RSE) Licence Number is L0001090. Retirement Wrap is a resident regulated superannuation fund within the meaning of the Superannuation Industry (Supervision) Act 1993 (SIS). BT Funds Management Limited ABN 63 002 916 458, AFSL Number 233724, RSE License No. L0001090 (BTFM), is the trustee of Retirement Wrap ABN 39 827 542 991.

8 The fund is not subject to a direction from the regulator not to accept employer contributions under section 63 of SIS.