AMG Insurance Application Form

Are you an adviser completing this form on behalf of your client? *

YesNo

INSURANCE APPLICATION

Please complete this form if you wish to apply online for voluntary or additional insurance cover through our group life insurer Hannover Life Re of Australasia (HLRA) .

Once you complete this form, you will receive an email from info@amgsuper.com.au within one business day that contains a secure URL allowing you to complete your application directly with HLRA. HLRA will request any further information needed, and health evidence required to complete the application. Please follow the instructions specified in their form.

If you have any questions regarding this application, please call our Client Services team on 1300 264 264 or email info@amgsuper.com.au.

For information on the different types of insurance available to you, the general terms of that insurance and the cost of insurance (premiums), please review the Product Disclosure Statement and Additional Information Bo oklet relevant to your account with AMG Super.

INSURANCE APPLICATION

Please complete this form if you wish to initiate the online application of voluntary or additional insurance cover for your client through our group life insurer Hannover Life Re of Australasia (HLRA).

Once you complete this form, your client will receive an email from info@amgsuper.com.au within one business day that contains a secure URL allowing your client to complete this application directly with Hannover Life Re of Australasia (HLRA). HLRA will request any further information needed from your client, and health evidence required to complete the application.

If you have any questions regarding this application, please call our Client Services team on 1300 264 264 or email info@amgsuper.com.au.

For information on the different types of insurance available to your client, the general terms of that insurance and the cost of insurance (premiums), please review the Product Disclosure Statement and Additional Information Bo oklet relevant to your clients account with AMG Super.

APPLICANT PERSONAL DETAILS

Member Number *

First Name *

Last Name *

Date of Birth *

Gender *

FemaleMale

Email Address *

Address *

ADVISER DETAILS

Adviser Name *

Adviser Phone Number *

Adviser Email Address *

Adviser Business Name *

INSURANCE DETAILS

If this is an application for new cover, please detail the total amount of cover you wish to apply for.

If this is an application for additional cover, please detail the total amount of cover you wish to have, including the cover you already have. For example: if you have $100,000 of Death Cover currently, and wish to increase it to $200,000 please put $200,000 in the Total Death Cover amount requested field.

Total Death Cover amount requested

Total TPD Cover amount requested

Total Group Income Protection Cover amount requested

Group Income Protection benefit payment period *

Group Income Protection Waiting Period *The waiting period is the length of time between when you are Totally or Partially Disabled and when benefits start being paid, provided this date is after cover has started.

I agree that the information provided above can be shared with HLRA as Group Insurer of the AMG Super Fund *

I confirm my client has agreed that the information provided above can be shared with HLRA as Group Insurer of the AMG Super Fund *

Note: Submitting this form does not mean you have insurance cover. The information provided will be sent to our group insurer HLRA. You will receive further instructions from us via email within one business day to progress your application.

Click here to view Hannover Re's privacy policy.

Note: Submitting this form does not mean your client has insurance cover. The information provided will be sent to our group insurer HLRA. Your client will receive further instructions from us via email within one business day to progress this application.

Click here to view Hannover Re's privacy policy.