Change of Details Form - Emplus

1 P PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E | W ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 1 of 5 Change of Details FormThis form is to be used when you want to amend your Details in your Emplus account. Please complete each section as required and sign the declaration. This form can be used by all members of a division of Emplus EXISTING PERSONAL DETAILSFull Name:Address:Date Of Birth:Member Number: To Change your personal Details , proceed to step 2. To Change your preferred beneficiary(ies), proceed to step 3. To Change your employment Details , proceed to step 4. To reduce your insurance cover, proceed to step 5. To cancel your insurance cover, proceed to step UPDATED PERSONAL DETAILSFull Name:Address:Date Of Birth:Member Number:Home Phone:Mobile Phone:Tax File Number [see Note 7]:Member Online: I would like to register for Member Online (please provide email address)Email Address:Important: For your Change of name to be registered on our records you must either attach a certified copy of your marriage certificate, or attach a certified copy of your certificate of Change of name (see Important Notes for more information).

2 3. YOUR Change OF BENEFICIARIESYou have the option of creating either a Preferred or a Binding nomination of Beneficiary to be used by the Trustee In the event of your death whilst a member of the Fund. Please note that a Preferred nomination of Beneficiary is not binding on the Trustee, who will take your wishes into account but has absolute discretion as to how your benefit will be paid. If you wish to create a Binding nomination of Beneficiary, you must use the Binding nomination of Beneficiary may revoke or Change your nomination at any time by completing a new nomination of beneficiaries read the Important Notes for more information about Nominated Beneficiary s Full NameRelationship% of BenefitTOTAL100%v20160101P PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E | W ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 2 of 54.

3 NEW EMPLOYMENT DETAILSO ccupation:Salary (gross):$paEmployment Basis:(full or part time, etc)Hours Per Week: (if not full time)Employer s Name: (business name) Effective Dateof Change :5. REDUCE MY INSURANCE COVERThis section is only to be used to reduce your existing insurance cover. If you wish to increase your cover, you should complete the Additional Insurance Personal Statement Application indicate the new level of cover you require. Fixed cover must be in multiples of $1,000. Your new level of TPD cover must not exceed your Death Cover. Please refer to the Product Disclosure Statement (PDS) for more Level of CoverUNITS OF COVERORFIXED COVERD eathUnits$TPDU nits$Declaration: I have read the PDS and I elect to reduce my cover. I understand that: Any cover I currently have, and the premium payable, will be reduced as from the date that the fund receives this fully completed Request. Should I wish to increase my cover in the future, I understand that I will be required to provide underwriting information, including evidence of good health satisfactory to the insurer and my cover will not commence until the insurer has accepted my application for cover in Signature:Date:/ /6.

4 CANCEL ALL INSURANCE COVERI would like to cancel all my insurance cover in the fundDeclaration: I have read the PDS and I elect to cancel all my insurance cover. I understand that: Any cover I currently have, and the premium payable, will be cancelled as from the date that the fund receives this fully completed Request. Should I wish to increase my cover in the future, I understand that I will be required to provide underwriting information, including evidence of good health satisfactory to the insurer and my cover will not commence until the insurer has accepted my application for cover in Signature:Date:/ /7. RETAIN MY INSURANCE COVERI would like to retain my insurance cover in the fund as indicated below:DeathTotal and Permanent DisablementSalary Continuance Income Protectionv20160101P PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E | W ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 3 of 58.

5 YOUR SIGNATURED eclaration: I have read and understood the current PDS. I have read and carefully considered the questions in this form and all the answers provided are to the best of my knowledge, true and correct. I understand that if I do not complete this form correctly, or I do not sign and date this form , my application will be invalid and will not be considered by the Insurer. I understand that if my application is accepted, all my insurance cover with Emplus Super will be based on the amount and type of cover and the occupation rating that I will be notified in writing. I have read the Duty of Disclosure section above, and understand my obligations under the Insurance Contracts Act 1984 I understand that the Duty of Disclosure continues after I have completed this form until my application has been accepted by onepath Life and confirmation is issued in writing. I have read and understood the Emplus Super s Privacy Statement contained in the Member Guide and onepath Life s Privacy Statement in this form , and authorise the collection, use, storage and disclosure of my personal information for the purposes of this application, as outlined in the Privacy Statement.

6 If I have provided information about another person in this application (for example a beneficiary or life insured), I declare that I have the consent of that person to do so. I understand that onepath Life require me to inform the person concerned that I have done so and direct them to the Privacy Policy which is located at I understand that my insurance cover is provided to me on the terms contained in Emplus Super s insurance policy with onepath Life as amended from time to Signature:Date:/ /We are committed to respecting the privacy of the personal information you give us. Our formal Privacy Statement sets out how we do this. If you would likea copy of Emplus Super s Privacy Statement, please let us know. We have published our Privacy Statement on our website at PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E | W ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 4 of 5v20160101 IMPORTANT NOTESP lease read these instructions before completing Section 2 of the Change of Details OF IDENTITY REQUIREMENTSW here you are requesting that your benefit be transferred to another fund, in accordance with Anti Money Laundering and Counter Terrorism Financing Act 2006 and for the security of your account, you must supply Proof of Identity documents before any payment can be made.

7 The only acceptable Proof of Identity documents are either:1. An original or certified* copy of a current primary photographic identification document such as a passport or driver s license;OR2. Both of an original or certified* copy of a primary non-photographic identification document such as a birth certificate, citizenship certificate or Centrelink pension or health card AND an original or certified* copy of a secondary identification document such as an assessment issued by the ATO to the person within the preceding 12 months that contains the name of the person and his or her residential address or a rates notice issued to the person within the preceding 3 months that contains the name of the person and his or her residential address or a Centrelink letter addressed to the person within the preceding 12 months regarding a Government assistance person who is authorised to certify documents must sight the original and the copy and make sure both documents are identical, then make sure all pages have been certified* as true copies by writing in English certified true copy (a stamp may be used instead)

8 Followed by their signature, printed name, qualification ( Justice of the Peace, Australia Post employee etc) and date. Contact Details must be supplied where the certification is not provided by a Justice of the the document being provided is a certified* copy, the copy must have original certification on it it cannot be a photocopy of a document that was previously certified*. Faxed or emailed copies of certified* documents do not comply with our identification requirements and are not note that we do not have any discretion over these requirements Proof of Identification is required under the Federal Government legislation and cannot be waived or amended in any YOU CHANGED YOUR NAME OR ARE YOU SIGNING ON BEHALF OF ANOTHER PERSON?If you have changed your name or are signing on behalf of the member, you will need to provide a certified* linking document. A linking document is a document that proves a relationship exists between two (or more) of NameSigned on behalf of MemberSuitable linking documentsMarriage certificate, Change of Name certificate from the Births, Deaths and Marriages Registration OfficeGuardianship papers or Power of Attorney.

9 * Certified means:The original documents and photocopies have been sighted by one of the following persons, who has then provided written confirmation on the photocopy that they are true and correct copies of the originals: A permanent employee of Australia Post with two or more years continuous service; A finance company officer with two or more years continuous service (with one or more finance companies); An officer with or authorised representative of a holder of an Australian Financial Services License (AFSL) having two or more years continuous service with one or more licensees; A notary public Officer; Member of the Police Force; A registrar or deputy registrar of a court; Justice of the Peace; A person enrolled on the roll of a State or Territory Supreme Court or the High Court of Australia, as a legal practitioner; An Australian consular of Australia or an Australian diplomatic officer; A judge of a court; Magistrate; A Chief Executive Officer of a Commonwealth court; Councillor of a Municipality; Registered Medical Practitioner; Dentist; Veterinary Practitioner; Pharmacist; Bank Branch Manager; Minister of religion; Teacher.

10 Person accredited as a Chartered PO Box 3528, Tingalpa DC QLD 4173 | T 1800 336 911 | F 07 3899 7299 | E | W ABN 18 838 658 991 RSE Registration Number R1067880 Issued by the trustee: Equity Trustees Limited ABN 46 004 031 298 AFS Licence No 240975 RSE Licence No L0003094 PAGE 5 of 5 DUTY OF DISCLOSUREThe Trustee who enters into a life insurance contract in respect of your life has a duty, before entering into the contract, to tell the insurer, onepath Life Limited (Insurer) anything that they know, or could reasonably be expected to know, may affect the Insurer s decision to provide the insurance and on what Trustee has this duty until the Insurer agrees to provide the Trustee has the same duty before they extend, vary or reinstate the Trustee does not need to tell the Insurer anything that: reduces the risk the Insurer insures you for; or is of common knowledge; or the Insurer knows or should know as an Insurer, or the Insurer waives your duty to tell the Insurer order for the Trustee to comply with the duty of disclosure, we require you to tell us [Trustee] and the Insurer, anything you know, or could reasonably be expected to know, that may affect the Insurer s decision to insure you and on what terms.