Microsoft word - metlife personal stmt doc _2_.doc

MetLife Insurance Ltd ABN 75 004 274 882 AFSL No. 238096 Group Insurance
Personal Statement and Declaration of Health
Preliminary – For the Administrator of the scheme or fund to complete:
1. Name of Scheme or Superannuation Fund:
□ Outside Eligibility □ Over Automatic Acceptance Limit
2. Reason for underwriting
□
No Automatic Acceptance Limit □ Other
Amount already insured
Amount currently requesting
(iii) Total insurance if the amount requested is accepted

For Completion by the Life Insured
Name of Employer and/or Member Number:

1. Surname First Names

Address
Email Address (if App) Contact Number/s:

Date of birth
2. Do you intend or are you likely to fly in an aircraft other than as a passenger on a scheduled commercial

3. Do you intend or are you likely to engage in any hazardous pursuit or pastime? If so, give details.

4. Name of your own Doctor
Address
How long has he/she known you?
If so give dates and details of these drugs.
7. Do you drink alcohol? If so, what form and what daily quantity?

8. Do you smoke? If so, what form and daily quantity?

9. Has any near relative suffered from diabetes, epilepsy, mental/nervous disorder or breakdown, or
tuberculosis, or committed suicide? If so, give particulars. _________________________________________________________________________________________ Please fill in the following schedule of family history:- 10. During THE LAST 5 YEARS have you had any medical examination, advice, treatment, or
been in hospital? If so, fill in particulars of each instance (including X-ray, electrocardiogram or other special tests) in the following schedule): Reason (if illness or injury, give duration and date of recovery) 11. Have you ever been advised to have an operation or do you contemplate surgery in the future? □ Yes
If yes, please provide details below or on a separate piece of paper. If “Yes”, give date, name and address of
Have you EVER had any of the following- doctor (if any), and full particulars,
including duration and any residual
problems
(c) Rheumatic fever or any heart complaint? (d) Asthma, tuberculosis, or any other lung (e) Indigestion, gastric or duodenal ulcer? (f) Bowel, liver or gall bladder disease? (g) Epilepsy, fainting attacks or fits of any kind? (h) Anxiety, depression, stress problems, mental, (i) Kidney or bladder disease, including renal (j) Diabetes, gout, cancer or tumor of any type? (k) Coughing of blood, passage of blood from (l) Rheumatism, sciatica or any back, neck, arthritis or joint problems including Chronic Fatigue, ME etc. (n) Do you have any physical defects, impaired (a) Are you suffering from AIDS or from any (b) Have you been injected with any drug not (c) Have you engaged in male to male sexual (d) Have you any reason to believe your spouse or sexual partner are suffering from AIDS or from any AIDS related disease or disorder? (e) Have you received a blood transfusion or treatment with human blood products prior to 1985?
14. Has a Proposal of Life, Accident or Sickness Insurance on your life ever been declined or deferred by, or
withdrawn from, any Insurance Company, or accepted with a loading exclusion or otherwise than as submitted? If so, give particulars of all such Proposals. Please give details of Company, Type of Insurance, Amount of Loading or Type of exclusion. 15. Do you have any other life, disability or trauma insurance with any other insurer? If yes, please provide
If yes, please detail sum insured/
monthly benefits
Duty of Disclosure
INSURANCE CONTRACTS ACT, 1984
Your Duty of Disclosure
Before you enter into a contract of Life Insurance with an insurer, you have a duty, under the
Insurance Contracts Act 1984, 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 the
insurance and, if so, on what terms.
You have the same duty to disclose those matters to the insurer before you vary or reinstate a contract of life insurance. Your Duty however does not require disclosure of a matter - - that diminishes the risk to be undertaken by the insurer; - that is common knowledge; - that your insurer knows or, in the ordinary course of business, ought to know; - as to which compliance with your duty is waived by the insurer; Non-disclosure
If you fail to comply with your duty of disclosure and the insurer would not have entered into the
contract on any terms if the failure had not occurred, the insurer may avoid the contract with 3 years
of entering into it. If your non-disclosure is fraudulent, the insurer may avoid the contract at any
time.
An insurer who is entitled to avoid a contract of life insurance may, within 3 years of entering into it,
elect not to avoid it but to reduce the sum that you have been insured for in accordance with a formula
that takes into account that the premium that would have been payable if you had disclosed all
relevant matters to the insurer.

Please note that your Duty of Disclosure continues until a Policy has been issued.

I declare that the answers to the above questions are true, and I have not deliberately withheld any
information material to the proposed assurance and I consent to MetLife Insurance seeking medical
information from any doctor who at any time I have consulted prior to the date hereof and I authorize
the giving of such information during the currency of the liability of MetLife Insurance. A photocopy
of this declaration shall be as valid an authority as the original.
Privacy
If you make a claim under this policy we may conduct investigations to assess the value and validity
of the claim. This may involve the use of investigation agents, legal advisors and the collection of
personal data that MetLife Insurance believes is relevant.
I have read and understood the privacy statements attached to this form and agreed to the collection,
use and disclosure of personal information as described in those statements.


Signature of Proposed Life Insured Date of Application
Office Use Only
Scheme number
Your Privacy at MetLife Insurance
Keeping customer information secure is a top priority for all of us at MetLife Insurance Ltd in Australia. We hope this notice helps you understand how we handle the personal information about you that we collect and how you can control our disclosure of information about you. The provisions of this notice will apply to former customers as well as our current customers unless we state otherwise. MetLife Insurance may share personal information with other MetLife Group companies to make it easier for customers to apply for accounts or services from these companies. In addition, sharing personal information can help you receive timely notice about products, services or other special offers that may be of interest and benefit to you from companies in the MetLife Group family or from selected third parties. MetLife in Australia is subject to the National Privacy Principles under the Privacy Act, and this document outlines how we intend to deliver all the rights and protections customers are entitled to. You can rely on similarly high standards wherever in the world you deal with a MetLife group company, due to the MetLife Privacy Promise for Consumers, followed by all members of the MetLife group family of companies. Where there are differences between the MetLife group Privacy Promise and Australia’s Privacy Act, the stronger protection always applies. MetLife Privacy Promise for Consumers
While information is the cornerstone of our ability to provide superior service, our most important asset is our customers’ trust. Keeping customer information secure, and using it only as our customers would want us to, is a top priority for all of us at MetLife. Here, then, is our promise to our individual customers: 1. We will safeguard, according to strict standards of security and confidentiality, any information our customers In Australia, we will give you an opportunity to opt out of receiving information about unrelated products from MetLife group companies, and we will not disclose your information for marketing purposes to unrelated companies unless you agree. 2. We will limit the collection and use of customer information to the minimum we require to deliver superior service to our customers, which includes advising our customers about our products, services and other opportunities, and to administer our business. 3. We will permit only authorized employees, who are trained in the proper handling of customer information, to have access to that information. Employees who violate our Privacy Promise will be subject to our normal disciplinary process. 4. We will not reveal customer information to any external organization unless we have previously informed the customer in disclosures or agreements, have been authorized by the customer, or are required by law or our regulators. 5. We will always maintain control over the confidentiality of our customer information. We may, however, facilitate relevant offers from reputable companies. These companies are not permitted to retain any customer information unless the customer has specifically expressed interest in their products or services. 6. We will tell customers in plain language, initially and at least once annually, how they may remove their names from marketing lists. At any time, customers can contact us to remove their names from such lists. In Australia, marketing material sent to prospective customers will always include information on how to opt out of receiving further marketing communications. 7. Whenever we hire other organizations to provide support services, we will require them to conform to our privacy standards and to allow us to audit them for compliance. 8. For purposes of credit reporting, verification, and risk management, we will exchange information about our customers with reputable reference sources and clearinghouse services. 9. We will not use or share – internally or externally – personally identifiable medical information for any purpose other than the underwriting or administration of a customer’s policy, claim or account, or as disclosed to the customer when the information is collected, or to which the customer consents. In Australia we will not disclose health information unless you agree or unless the use is directly related to providing the service for which we collected the information. 10. We will attempt to keep customer files complete, up to date, and accurate. We will tell our customers how and where to conveniently access their account information (except when we’re prohibited by law) and how to notify us about errors which we will promptly correct. Our Policies and Practices to Protect Your Personal Information
We protect the personal information we collect about you by maintaining physical, electronic and procedural safeguards that meet or exceed applicable law. We require third parties that process personal information on our behalf to follow stringent standards of security and confidentiality. We train people who work for us how to properly handle personal information and we restrict access to what is necessary for specific job functions. Categories of Personal Information We Collect and Hold
The nature of the personal information we collect, and where it comes from, will vary according to the specific product, and may include: • Information we collect from you on applications or other forms, such as name, address telephone number, • Information about your transactions with us, our affiliates, or third parties, such as account balances, payment • Information we receive from credit bureau reports; • Health information for insurance products. Purposes of Collecting Your Information
We will only collect personal information necessary for the product/service. These purposes may include: • Processing a product application; • Evaluation and monitoring credit worthiness; • Processing receipts and payments, and servicing customer's accounts; • Responding to customer inquiries about applications, accounts or services; • Understanding customer's needs and offering products and services to meet those needs; • Allowing our affiliates and selected third parties to promote their products and services to customers; • Assessing, processing and investigating insurance risks or claims; • Meeting legal and regulatory requirements. We will not disclose any of the above information that we collect to affiliates or third parties without your consent. Disclosures of Your Information
In common with many organisations, we keep our costs down by obtaining some routine services from external service providers, and your information may be provided to them on a confidential basis. These disclosures and others to third parties may be for: • Cheque and statement printing and other administrative services; • Legal, settlement and valuation services; • Data processing and market research services; • Regulatory and compliance purposes; • Financial and professional advisory services; • Updating of credit information to credit bureaus; • Participating in payment systems, for example bank clearing and credit card associations; • Underwriting and assessing insurance risk and claims. We can provide a list of third parties to whom we may disclose information on request. Categories of Affiliates with Whom We May Share Your Information
Our affiliates are the family of companies that form MetLife. In accordance with the National Privacy Principles enshrined in the Privacy Act, we will disclose to you at or around the time of collecting personal information from you that we may share your information with affiliates. These affiliates operate in several different lines of business including banking, credit cards, consumer finance, securities and insurance. Contact Us
If you wish to find out more information, or raise any specific or general concerns about MetLife and its Privacy Policy, the contact details are as follows: MetLife Privacy Officer P.O. Box 3319 Sydney NSW 2001 Complaints and Disputes
If you have reason to believe that any MetLife affiliate or department has breached the Privacy Policies outlined in this document, we urge you to raise this with the MetLife Privacy Officer. To make this easier, you can obtain a form on request from the MetLife Privacy Officer, for you to describe and send in your concern. We will investigate all complaints and respond to you within 14 days. If we find a complaint justified, we will promptly resolve it. If necessary, we will change policies and procedures to maintain our high standard of performance, service and customer care. This is your right under the Privacy Act. You are entitled under the Privacy Act to access the information an organisation holds about you. We want to make this as simple as possible for you. You can obtain a form from the MetLife Privacy Officer for this purpose, though you can make the request in the letter or by telephone if you prefer. Given the range and diversity of MetLife’s operations in Australia, to help us locate and provide the information you request, we would ask that you be reasonably specific about the information you require, and take a few minutes to complete the form. We will need to validate the identity of anyone making an access request, to ensure that we do not provide your information to anyone who does not have the right to the information. Where the customer establishes that the personal information we hold on them is not accurate, complete or up-to-date we will correct our records as necessary. We may charge you an administration fee for providing access in accordance with your request. Your request will usually receive a response within 30 days. Access to information about you is your right under the Privacy Act. Your Privacy Preferences
Please remember that we will protect your personal information regardless of your privacy preferences. If you do not wish us or other companies to communicate marketing offers to you, you may use the following methods to inform us. Please do not include account numbers or other sensitive data in email, since it may not be secure. Alternatively, you may use the consumer preference facilities offered by the Australian Direct Marketing Association (ADMA). Note this should stop you receiving unsolicited direct marketing from participating ADMA members. Reply Paid 38 PO Box 464 Kings Cross NSW 1340 http://www.adma.com.au/consumer/callRegistration.asp http://www.e-mps.org/en/ind_static.html * References to MetLife group in this notice refer to MetLife Insurance Limited (ABN 75 004 274 882) and it’s affiliates depending on which company is maintaining your account or providing you with products or service

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