[PDF] Defined Benefit Account Disability Claim - QSuper - Queensland

Defined Benefit AccountDisability ClaimPlease refer to the notes on page 4 where you see this symbol.Also see the additional information about the form on page 5.Please complete in dark blue or black ink.What do I use this form for?You can use this form to transfer your benefit to a QSuper Accumulation account, make a cash withdrawal or start a lifetimepension.Alternatively, if you would like to open an Income account you’ll need to read the Income Account Product Disclosure Statement(PDS) and complete the application form included. If you’d like to transfer your benefit to another super fund you’ll need tocomplete the Transfer to Another Super Fund form. Both the Income Account PDS and Transfer to Another Super Fund form can bedownloaded from our website, or call us and we’ll send you the copy you need.You can stay with QSuper. With QSuper, you pay no entry and no exit fees – just one management fee. Keeping yourmoney within superannuation means your money remains in a concessionally taxed environment. It also means you canwithdraw non-preserved money from your account whenever you want (with a minimum withdrawal of $2,000).Part AQSuper account detailsPlease enter your QSuper client number in the box below.Client numberYou can find your client number on your benefit statement.Part BPersonal detailsMr/Mrs/Miss/Ms/Dr/other (please specify)SurnameGiven namesResidential addressPostal addressStatePostcodeDate of birth (dd/mm/yyyy)StatePrevious name (optional - only if we still use your previous name)PostcodePhone number (home) Phone number (work) Phone number (mobile)Email addressI consent to QSuper sending information by email. As it becomes available, I would like to receive benefit statements, product disclosurestatements, significant event notices and other information QSuper is required to provide by law and updates on services and products by emailinstead of being posted.Please read the note in additional information about the form on page 5 before providing your TFN.Tax file number (TFN)If you have previously given your TFN to QSuperyou do not need to supply it again.Continued over page1/8

Defined Benefit Account Disability Claim continuedPart CWithdrawal optionsOption 1 – Transfer to a QSuper Accumulation account$or% of your accountThese instructions will apply to all money withdrawn using option 1. This includes your defined benefit plus anyattached Accumulation monies, such as voluntary contributions, you may have paid to this account.I request the QSuper Board of Trustees invest the total amount, including all voluntary contributions, in the following option/s:Investment option Amount PercentageLifetime $ or %Moderate $ or %Balanced $ or %Socially Responsible $ or %Aggressive $ or %Cash $ or %If you do not nominate aninvestment preference, yourmoney will be invested in theQSuper Lifetime option.Contributions cannot be investeddirectly into Self Invest. To transfermoney to Self Invest log intoMember Online.Diversified Bonds $ or %International Shares $ or %Australian Shares $ or %Total $ or 100%Option 2 – Pay benefit as a pension payable for life (only applicable for eligible members)If you’re under age 60, please attach a Tax File Number Declaration form. Call us if you would like one sent to you.Option 3 – Pay directly into a personal account$ gross (before tax)or$ net (after tax)or% of your accountIf you select option 2 or 3, payments can only be made to a bank, credit union or building society account in yourname/joint names. Payments can’t be made to a business account. If you have an overseas bank account you mustprovide us a copy of a bank statement that shows your full name, address and account details before we can make apayment. This must include your account number, account name and SWIFT/Branch Identifier Code (BIC). We cannotprocess a payment to an overseas bank account without this.Name of bank, credit union or building societyAccount nameAccount numberBranch (BSB) numberQSuper doesn’t accept responsibility for any delay or loss caused by providing incorrect details.2/8

Defined Benefit Account Disability Claim continuedPart DIdentification requirementsThe QSuper Board is committed to complying with the Anti‐Money Laundering And Counter-Terrorism Financing Act 2006. In linewith QSuper’s anti-money laundering and counter-terrorism program, we require identification details with any claim you initiateon your QSuper account or as part of a claim as a beneficiary of a QSuper member’s account. If you are acting on behalf of aQSuper member (e.g. under a power of attorney), both you and the QSuper member must supply identification as described in theProviding Proof of Identity factsheet which can be downloaded from our website or call us and we’ll send you a copy.Part EProving your identityYou have two options to prove your identity:OROption 1 – Provide the information below and QSuper will confirm your identity electronically. If we cannot verify your identityelectronically we will contact you to request certified copies of your identification documents. This is not a credit check, andthe information is only used to verify your identity.I have read the information in the Proving Your Identity factsheet and consent to QSuper Limited disclosing my name,residential address and date of birth to a credit reporting agency to assist in verifying my identity for the purposes of theAML/CTF Act.Drivers Licence/Proof of Age card number Passport numberorOption 2 – Attach certified copies of your identification document as explained in the Proving Your Identity factsheet.If you are currently overseas you’ll need to provide certified copies of your identification.Part FDeclaration and authorisationFinding your other super. With your permission we can useyour TFN to search with the ATO for any other superannuationyou may have. This could include lost super, other activeaccounts, and any other ATO held monies (includingSuperannuation Guarantee, co-contribution entitlements andunclaimed monies).If we locate any other super for you, we will write to you to seeif you would like us to consolidate the funds in to QSuper onyour behalf. You can remove this consent by calling, writing oremailing us.I consent to QSuper finding my other super.• I declare I am the person named on this form, or have apower of attorney to act on the member’s behalf.• I request payment to be made in the manner indicatedon this form and accompanying material.• I declare the information given on this form is trueand correct.• I authorise QSuper to release details of my TFN to the ATOand to the other fund.• If under age 60, I understand tax may be deducted from thecash withdrawal.• I authorise QSuper to obtain personal information aboutme from my employer to ensure I receive the correctentitlements that are due to me.• I declare I am an Australian or New Zealand citizen,or a permanent resident of Australia.• I understand that should a surcharge debt apply anda withdrawal request from QSuper be made, it will bededucted prior to the payment of the withdrawal.• I have supplied the necessary documentation to complywith the Anti-Money Laundering and Counter-TerrorismFinancing Act 2006, as outlined in the Providing Proof ofIdentity factsheet.1 You must supply an original certified copy of the power of attorney documentto QSuper unless you have already done so.SignatureDate (dd/mm/yyyy)Continued over page3/8

Defined Benefit Account Disability Claim continuedImportant notesPart C (option 1) You can leave your benefit in a QSuperAccumulation account while continuing to have access to yourunrestricted non-preserved amount. Partial withdrawals mustbe at least $2,000. You must withdraw your entire benefit if youwant to make a partial withdrawal and your account balance isless than $2,000. The unit price on the date of payment will beapplied to your withdrawal.For more information you should read the AccumulationAccount Product Disclosure Statement. You can download a copyfrom our website or call us and we’ll send you a copy.Checklist – making sure your claim is paidQSuper wants to make sure your claim is processed as quickly and easily as possible. To help us do this, please take a few momentsto review the following checklist – it will help ensure you complete this form correctly, and remind you to attach any necessarydocuments before sending this form to us.Did you provide all your relevant details in part B (page 1)?Did you provide your TFN (if needed)?Have you selected what kind of withdrawal you want to make in part C (page 2)?If you selected option 1 in part C (page 2), have you chosen the investment option/s you want your money to be invested in?If you selected option 2 in part C (page 2) and are under age 60, have you attached a Tax File Number Declaration form?Did you provide the identification outlined on the following Proving Your Identity factsheet (if required)?Have you signed the declaration and authorisation in part F (page 3)?Have you had your Employer Certification of Employment Details completed by your employer and provided a copy with this claim form?4/8

Defined Benefit Account Disability Claim continuedAdditional information about the formProviding your tax file number (TFN)Under the Superannuation Industry (Supervision) Act 1993, your superannuation fund is authorised to collect your TFN,which will only be used for lawful purposes.These purposes may change in the future as a result of legislative change. The trustee of your superannuation fund maydisclose your TFN to another superannuation provider when your benefits are being transferred, unless you request thetrustee of your superannuation fund in writing that your TFN not be disclosed to any other superannuation provider.It is not an offence not to quote your TFN. However, giving your TFN to your superannuation fund will have thefollowing advantages (which may not otherwise apply):• your superannuation fund will be able to accept all types of contributions to your account/s• the tax on contributions to your superannuation account/s will not increase• other than the tax that may ordinarily apply, no additional tax will be deducted when you start drawing downyour superannuation benefits• it will make it much easier to trace different superannuation accounts in your name so that you receive all yoursuperannuation benefits when you retire.In accordance with Australian Government legislation, for partialwithdrawals, QSuper will withdraw your money proportionatelyfrom the two tax components held in your account. Please referto the Tax Explanation factsheet for further information.QSuper aims to process your claim within six working days fromthe date this form is received, as long as all required informationhas been provided. Your claim cannot be processed untilthe attached employer certification has been completed byyour employer.If you are taking care of the member’s affairs due to a power ofattorney or an enduring power of attorney, you need to supplyus with an original or a copy of this document, certified as a trueand complete copy of the original under the Powers of AttorneyAct 1998. This certification can be done by a justice of the peace,commissioner for declarations, lawyer or notary public.Original documents will be returned to you once the paymenthas been finalised.Please ensure your employer completes the attached certification. Your payment cannot be made without thiscompleted form.Continued over page5/8

Defined Benefit Account Disability Claim continuedHow long will it take for my claim to be processed?QSuper can generally process your claim within six working days of receiving this form, along with any necessary additionaldocuments, provided you have stopped working for the Queensland Government.Once QSuper has processed your claim, please allow one to two days for your bank, credit union or building society to put yourmoney in your account.6/8Contact Centres 70 Eagle Street Brisbane and 63 George Street BrisbaneTelephone 1300 360 750 (+61 7 3239 1004 if overseas)Monday – Friday 8.30am to 5.00pm AEST© QSuper Board of Trustees 2014Postal address GPO Box 200 Brisbane Qld 4001Fax 1300 242 070Website qsuper.qld.gov.auABN: 60 905 115 063SFN: 2610 419 417939 30/09/14FO37This form is issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN 32 125 059 006) (QSuper Board). All products are issued by the QSuperBoard as trustee for the QSuper Fund (ABN 60 905 115 063). The privacy of your personal information is important to us. QSuper Limited (ABN 50 125 248 286, AFSL 334546) iscollecting this information on behalf of the QSuper Board to administer your superannuation account. This is authorised under the Superannuation (State Public Sector) Act 1990.This information may be disclosed to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies.QSuper may also disclose this information to third parties if it is necessary in providing our products and services to you, or you have consented to the disclosure, or disclosureis required by law. If you would like further information about our privacy policy, you can download QSuper’s Your Privacy factsheet from our website. Alternatively, call us andwe’ll send you a copy. Where the term ‘QSuper’ is used in this form, it represents the QSuper Board, the QSuper Fund and QSuper Limited, unless expressly indicated otherwise.

Employer Certification of Employment Details continuedPart BEmployer detailsPay office code Phone number Name of authorised officerSignatureDate (dd/mm/yyyy)Additional information and checklistQSuper is unable to process your employee’s claim until all these details are provided.Please complete this form and forward it to QSuper.Have you provided correct full-time equivalent salaries for the past two years?Have you provided the employee’s fortnightly OTE salary at the employee’s termination date?Have you provided details of the final contributions in respect of this employee?Have you provided your details to us, including the pay office code?Please attach additional documentation if necessary.Contact Centres 70 Eagle Street Brisbane and 63 George Street BrisbaneTelephone 1300 360 750 (+61 7 3239 1004 if overseas)Monday – Friday 8.30am to 5.00pm AEST8/8 © QSuper Board of Trustees 2014Postal address GPO Box 200 Brisbane Qld 4001Fax 1300 242 070Website qsuper.qld.gov.auABN: 60 905 115 063SFN: 2610 419 417939 30/09/14FO37This form is issued by the Board of Trustees of the State Public Sector Superannuation Scheme (ABN 32 125 059 006) (QSuper Board). All products are issued by the QSuperBoard as trustee for the QSuper Fund (ABN 60 905 115 063). The privacy of your personal information is important to us. QSuper Limited (ABN 50 125 248 286, AFSL 334546) iscollecting this information on behalf of the QSuper Board to administer your superannuation account. This is authorised under the Superannuation (State Public Sector) Act 1990.This information may be disclosed to your employer, authorised service providers (e.g. external insurers), other superannuation funds and government departments or agencies.QSuper may also disclose this information to third parties if it is necessary in providing our products and services to you, or you have consented to the disclosure, or disclosureis required by law. If you would like further information about our privacy policy, you can download QSuper’s Your Privacy factsheet from our website. Alternatively, call us andwe’ll send you a copy. Where the term ‘QSuper’ is used in this form, it represents the QSuper Board, the QSuper Fund and QSuper Limited, unless expressly indicated otherwise.