Income Protection Benefit Guide - QSuper Guide - Education Queensland

 
QSuper Guide

       Income Protection
          Benefit Guide

               Issued: 23 January 2018
2

Income Protection Benefit Guide

Contents
Your income protection insurance             3
How do I apply?                              5
How is my benefit paid?                      6
Review and appeal process                    7
Income Protection Benefit Application form
3

                                                                                                                                                         Income Protection Benefit Guide

Your income protection insurance
From 1 July 2016 we’ve got some new insurance arrangements in place to give you even greater peace of mind.
When it comes to determining what terms and conditions your claim will be assessed against, what’s important is not the date you make the
claim, but what’s known as the date of disablement. Even if you submit your claim from 1 July 2016, if the date of disablement was on 30 June
2016 or earlier, your claim will be assessed based on the level of cover and the terms and conditions that applied at the date of disablement.

About this guide
This guide explains what you need to do to make a claim for income protection benefits. If you’re a QSuper member with income protection
you might be eligible to receive a regular income for up to two or three years (depending on your employment arrangements and date of
disablement) if you’re temporarily unable to work due to an illness or injury. If you’ve personalised your cover, you may be entitled to income
protection benefits up to five years or to age 65, depending on the cover you’ve chosen. However if you have a Defined Benefit account, your
maximum income protection cover is up to two years.

Overview of your income protection cover
Here’s a quick reference to your default income protection cover. If you were a member before 1 July 2016 and previously cancelled cover,
default cover is not automatically applied.

  Default cover from 1 July 2017

  I work for                                                       Waiting and benefit periods                                       Your benefit

  The Queensland Government as a                                   Accrued sick leave plus 14 days and payable                       If you are aged 16-64 we’ll pay 87.75% of
  permanent or temporary employee                                  for up to three years.                                            your insured salary (including a Contribution
  and make standard contributions to my                                                                                              Replacement Benefit of 12.75% of insured
  Accumulation account.                                                                                                              salary¹).
  (If you’re a Member of the Legislative                                                                                             Maximum benefit limits apply.
  Assembly, you aren’t eligible for income
  protection cover.)

  A default employer, or the Queensland                            90 days or your accrued sick leave, whichever If you are aged 16-64 we’ll pay 87.75% of
  Government as a permanent or temporary                           is greater, and payable for up to three years. your insured salary (including a Contribution
  employee and don’t make standard                                                                                Replacement Benefit of 12.75% of insured
  contributions.                                                                                                  salary¹).
                                                                                                                                     Maximum benefit limits apply.

  The Queensland Police Service as a police                        Accrued sick leave plus approved                                  If you are aged 16-64 we’ll pay 87.75% of
  officer.                                                         Queensland Police Service sick leave bank or                      your insured salary (including a Contribution
                                                                   180 days, whichever is greater, and payable                       Replacement Benefit of 12.75% of insured
                                                                   for up to two years.                                              salary¹)
                                                                                                                                     Maximum benefit limits apply.

  A default employer or the Queensland                             You’re not automatically covered with default income protection cover, however you may
  Government as a casual employee, or my                           be able to apply for income protection insurance if you’re eligible.
  account was opened as either:
  • I have applied for an Accumulation account
     direct with QSuper (not through my
     employer)
  • A spouse of a QSuper member, or
  • A result of a family law split
  or
  • I have an Income account, and an
     Accumulation account was opened
     for me with a contribution (including
     consolidation from another fund).

1 Insured salary is your salary on which employer contributions are paid to QSuper and for the avoidance of doubt employer contributions do not include salary sacrifice contributions. For the
purpose of claims, insured salary will be calculated as at the date of disablement or, if you are gainfully employed on a casual basis, an averaged amount based on the period of 3 months prior
to the date of disablement (or over your most recent period of employment, if shorter).
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Income Protection Benefit Guide

If you’ve personalised your income protection cover, your waiting                         You should also know that if your condition is linked to an illness or
period, and/or benefit period and the benefit payable will be as                          injury where the date of disablement was before 1 July 2016 and
per your approved application. You can find this by logging onto                          you start to receive an income protection benefit payment, the
Member Online. (All benefits are subject to benefit cap limits.)                          maximum benefit period available will be two years and not three.
One thing to note - if you’ve previously received an income
protection benefit from QSuper and you need to make a claim for                           What about pre-existing conditions and other
the same or a related condition, your maximum benefit period will                         exclusions?
be reduced by the total number of weeks you received a benefit
from all previous claims related to that condition.                                       Some of our cover comes with what’s known as a pre-existing
                                                                                          exclusion period, which is the period during which we won’t pay
                                                                                          an insurance benefit if the illness or injury you’re claiming is related
What if my date of disablement was before                                                 to a pre-existing condition.
1 July 2016?
                                                                                          If your date of disablement is on or before 30 June 2016, a five year
If you were a QSuper member before 1 July 2016 and your claim                             pre-existing exclusion period may apply.
relates to a date of disablement prior to 1 July 2016, your claim will
                                                                                          From 1 July 2016, default income protection cover has no pre-
be assessed under the terms and conditions that applied under
                                                                                          existing exclusion period provided you’re At Work on the day cover
your previous insurance arrangements.
                                                                                          starts (some exceptions apply).
    Cover overview (if membership and date of disablement is prior                        In all cases, where a pre-existing exclusion period applies and
    to 1 July 2016)                                                                       you’re not At Work on the day the pre-existing exclusion period
                                                                                          expires, the pre-existing exclusion period will continue to apply
                                 Waiting and                                              until you have been At Work for 30 consecutive days.
    I work for                                                 Your benefit
                                 benefit periods
                                                                                          There’s more detailed information about pre-existing exclusion
    The Queensland               14 days after you             We’ll pay 75% of           periods and other exclusions and how they apply refer to the
    Government or                use up all your               your salary1 for up to     Accumulation Account Insurance Guide.
    a related entity             paid sick leave,              two years. We’ll also
    employer as                  and your employer             keep paying your
    a permanent                  approves sick leave           super contributions
    or temporary                 without pay.                  of 17.75% of your
    employee and                 Payable for up to             salary.1
    make standard                2 years.
    contributions to
    my Accumulation
    account. (If you’re
    a member of
    the Legislative
    Assembly you aren’t
    eligible for income
    protection cover.)

    A non-Queensland             30 days of being              We’ll pay up to
    Government or                totally unable                75% of your earned
    related entity               to perform your               income up to
    employer and                 occupation.                   a maximum of
    you have income              Payable for up to             $25,000 per month.
    protection cover.            2 years.                      Your cover is made
                                                               up of units with
                                                               each unit being
                                                               worth $1,000 per
                                                               month.

    Police officers              An income protection benefit is not
                                 provided by QSuper

1 The salary used for the purpose of calculating your income protection benefit is your
salary for superannuation purposes.
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                                                                                                              Income Protection Benefit Guide

How do I apply?
How do I apply for an income protection                                 What if I’m working higher duties when I make
benefit?                                                                a claim?
Like most insurance claims, there’s some paperwork you need             We do recognise higher duties, but just bear in mind you need to
to complete to apply for QSuper income protection benefit. You          have been working in the position continuously for at least
need to:                                                                12 months to have your benefit calculated at the higher salary
                                                                        if you’re an Accumulation account holder. For Defined Benefit
• complete the three parts of the Income Protection Benefit Claim
                                                                        account holders, you need to have been working in the
  form at the back of this guide
                                                                        higher-paid position for at least 12 months at the annual
• a ttach copies of any medical documents you already have on          review date of 1 July.
   your condition
• provide details on your work history and your income                 Let us know if your situation changes
• complete a Tax File Number Declaration form (you can get this        You must notify QSuper if you:
   from the ATO, newsagents, your employer, or call us and we’ll        • r eturn to work or start new employment
   send you one). Just remember that if you don’t provide your TFN,
   your benefit might be taxed at a higher rate.                        • s tart an approved graduated return to work program

It’s important you know that you need to cover any costs charged        • t ake any leave other than approved sick leave without pay
by your doctor to complete the Doctor’s Statement (Part C) of the       • c ease to be an Australian Resident
Income Protection Benefit Claim form.
                                                                        • intend to live outside Australia for greater than 6 months
We’ve tried to make claiming as simple as possible, but please get
in touch with us if you need any help completing the form.              • e arn additional income

When you complete this form, remember to include important              • engage in a business or occupation.
information that’s relevant to your claim. If you provide information   To prevent overpayment of your benefit, it’s important that you
that’s not accurate or true, we might have to reduce the amount of      notify us as soon as possible if any of the above occurs. If there is
income protection we pay you, or even stop your benefit and ask         any overpayment of benefits we will ask you to repay QSuper.
you to repay QSuper for any overpayments.
Please send your completed paperwork to us at                           What happens if my condition becomes
QSuper, Claims Operations,                                              permanent?
GPO Box 200,
Brisbane Qld 4001.                                                      If you become permanently disabled your income protection
                                                                        benefit will stop, unless you’ve personalised your income
How do you assess my claim?                                             protection cover to a 5 year period or to age 65. Then the income
                                                                        protection cover will continue on that basis.
We work as hard as we can to assess your claim as quickly as
possible. Once we receive all the necessary paperwork from you,
you’ll be allocated a claims manager and they’ll contact you to talk
you through the claims process and answer any questions you
might have about your claim.
If we need further medical information from you, we might ask you
to provide a medical report about your medical history. We’ll cover
costs to get this additional medical information.
If your claim isn’t approved, we’ll send you a statement explaining
the reasons for our decision. We explain on page 7 of this guide
what you can do if you’re not happy with our decision.
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Income Protection Benefit Guide

How is my benefit paid?
Once we approve your claim, payments will be made into your              If your claim relates to an illness or injury which occurred before
bank, credit union or building society account.                          1 July 2016, reasons we might stop paying your benefit include
                                                                         that you:
If you have an Accumulation account and salary-based income
protection cover, your income protection payments include a              • a re no longer on approved sick leave without pay
contribution replacement benefit (CRB) of 12.75% of your insured
                                                                         • d
                                                                            on’t provide medical information we’ve requested
salary which is paid to your Accumulation account.
                                                                         • d
                                                                            on’t attend a medical assessment we’ve arranged
If you have a Defined Benefit account, your super continues to
grow while you’re receiving an income protection benefit (in the         • s tart working your normal working hours again
same way it would if you were working).
                                                                         • r eceive WorkCover benefits
Please remember to make other arrangements for any other
                                                                         • a re paid for the maximum two year benefit period
payments that are automatically taken out of your pay such as
private health insurance premiums, child support or voluntary            • c hange your employment status to casual
super contributions while you’re on income protection.
                                                                         • s top working for an eligible QSuper employer
If you were a member before 1 July 2016 and your claim relates to
                                                                         • if you are employed by the Queensland Government, you no
an illness or injury which occurred before 1 July 2016 and you were
                                                                           longer meet the definition of temporary disablement. If you are
working for the Queensland Government or a related entity, your
                                                                           not employed by the Queensland Government, you no longer
approved income protection payment will be backdated to the
                                                                           meet the definition of Total Disability or Partial Disability.
start of your third week of sick leave without pay. Payments will be
made weekly and super contributions of 17.75% of your salary will
be made while you’re receiving income protection.                        What do I need to do while I’m receiving an
If you were a member before 1 July 2016 and your claim relates to
                                                                         income protection benefit?
an illness or injury which occurred before 1 July 2016 and you’re        While we’re paying you an income protection benefit we might
working for someone other than the Queensland Government or              ask you to:
a related entity employer, payments for approved claims will be
backdated to the end of the 30-day waiting period. We’ll pay you         • g
                                                                            et medical report forms completed on a regular basis by your
monthly, in arrears.                                                       GP or medical specialist
                                                                         • g
                                                                            et detailed medical reports (from your GP or medical specialist)
Are there any reasons you might stop my
                                                                         • a ttend independent medical or other assessments by specialists
income protection benefit?                                                  we nominate (your employer might also request this)
Yes, there are a number of reasons we might stop paying your             • h
                                                                            ave an interview over the phone or in person with our staff or
benefit. If your date of disability occurs after 30 June 2016 the          agent/s
reasons include:
                                                                         • p
                                                                            articipate in rehabilitation or return to work programs.
• y ou no longer meet the definition of total and temporary
   disablement or partial and temporary disablement                      This just helps us work out if you’re still eligible to continue to
                                                                         receive income protection.
• you turn 65 (or 60 if you’re a police officer)
• you come to the end of your benefit payment period
• you’re determined by the Board to be suffering a total and
   permanent disablement or to have a terminal illness, unless you
   have a 5 year or to age 65 benefit period
• if it is determined your condition is a pre-existing condition, and
   you have a pre-existing exclusion period attached to
   your cover
• y ou become engaged in a new business or occupation (unless it
   is part of an agreed graduated return to work program)
• y ou stop following the advice of an appropriate medical
   practitioner
• you choose not to participate, or to continue to participate, in an
   approved rehabilitation or retraining program
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                                                                                                               Income Protection Benefit Guide

Graduated return to work program                                          Additional info about this guide
As you recover from your illness or injury, you might ease back           Make sure you read the Accumulation Account Insurance Guide and
into work as part of a graduated return to work program. If this          this guide before you complete the Income Protection Benefit Claim
happens, your employer will pay for the hours you work, and we’ll         form that’s attached to the guide. And keep the guide somewhere
pay a percentage of the difference between your insured salary            handy in case you need to refer to it.
(or pre-disability income if your cover is in units) and your reduced
                                                                          To make a claim you need to complete all three parts of the Income
salary.
                                                                          Protection Benefit Claim form:
So even if you return to work you’ll still receive a partial benefit if
                                                                          •	the member statement (Part A) needs to be completed by
you continue to be disabled. For example if you return to work at
                                                                             you, and make sure you attach all available medical certificates
40 per cent of your insured salary (or pre-disability income) we will
                                                                             describing your illness or injury and any other relevant medical
pay you 60 per cent of your income protection benefit.
                                                                             information along with details of any additional income or
To help you further, if your claim relates to a date of disablement          earnings from other employment or any business you may be
on or after 1 July 2016, and you return to work for at least                 involved in
20 per cent of your substantive hours you may be eligible for the
                                                                          •	the employer’s statement (Part B) needs to be completed by
graduated return to work additional payment for a period of up to
                                                                             your employer
eight weeks. This benefit may increase your total benefit payment.
For more details about the calculation refer to the Accumulation          •	the doctor’s statement (Part C) needs to be completed by your
Account Insurance Guide. Graduated return to work additional                 medical practitioner or specialist.
payments will end as soon as:
                                                                          It’s important the claim form is completed in full before it’s sent to
• y ou stop participating in an approved graduated return to work        us or your claim could be delayed.
   program or
                                                                          We can only pay your benefit into your bank, credit union or
• you return, or are able to return to work at your substantive hours    building society account. This means we can’t pay it into a business
   or                                                                     or loan account. You should know that if you provide incorrect
                                                                          details, there could be a delay in your payment or a loss of interest,
• t he graduated return to work additional payment has been paid
                                                                          and we can’t accept responsibility for this.
   for eight weeks.

Review and appeal process
What if I’m not happy with the decision?                                  What is the Superannuation Complaints
We understand not everyone will be happy with the decisions               Tribunal (SCT)?
made about their claims and you’re welcome to lodge an appeal             The SCT is an independent tribunal set up by the Commonwealth
for review by QSuper. Send your appeal in writing to: Quality and         Government to review complaints relating to decisions made by
Compliance, Operations, QSuper, GPO Box 200, Brisbane Qld 4001.           super funds.
Remember, you need to cover any costs to obtain medical reports
to support your appeal.                                                   But please bear in mind you need to use our internal appeal
                                                                          process before going to the SCT. If you’re not happy with the
If you’re still not satisfied with the review decision, you can lodge a   review decision or we haven’t contacted you within 90 days of
complaint with the Superannuation Complaints Tribunal. The SCT            lodging your appeal, call the SCT on 1300 884 114. They’ll let you
imposes time limits within which to lodge a complaint with them.          know if they can deal with your complaint and the information
Please contact the SCT directly to ascertain your eligibility to lodge    you’ll need to provide. You can visit the SCT website at sct.gov.au
a complaint.                                                              for further information.
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Income Protection Benefit Guide
QSuper Form                                                                                 Please complete in block letters, in blue or black ink.
                                                                                                                                                               1

Income Protection Benefit Claim
(Part A) – Member Statement
Who needs to complete this form?
You need to complete this part of the claim form to apply for income protection. We need detailed information about your job and your
illness or injury to be able to assess your claim. And please make sure you provide your medical practitioner’s details in case we need to get in
touch with them for more information. If you need any help completing this form, please give us a call.

  1       Personal details              You can find your client               2      Details of your medical condition
                                        number on your annual
Client number                           statement or by logging              Please attach copies of any medical evidence you already have
                                        in to Member Online.                 on your illness or injury, and any other relevant information.
                                                                             Name of your illness or injury (please provide a detailed description)
Title         Given names

Surname
                                                                             What was the cause of your illness or injury?

Previous name1 (if we know you by another name)

Date of birth (dd/mm/yyyy)           Home phone number                       Are you receiving, or are you willing to receive, appropriate
                                                                             medical care that’s recommended by your treating medical
                                                                             practitioners?
Mobile phone number
                                                                                   Yes             No
                                                                             What treatment are you currently receiving?
Email address

                                                                             When did you start your
Residential address                                                          treatment? (dd/mm/yyyy)                         Frequency

                                                                             When was your illness first diagnosed or date you were injured?
                                                                             (dd/mm/yyyy)
                             State            Postcode
Postal address               As above
                                                                             When did you first see a doctor about your illness or injury?
                                                                             (dd/mm/yyyy)

                             State            Postcode                       When did you first stop working because of your illness?
                                                                             (dd/mm/yyyy)
Name of your employer                Payroll number

                                                                             Have you started a graduated return to work program? If yes, please
HR/payroll contact name              HR/payroll contact number               specify the date this started.
                                                                                   Yes             No

Are you employed or self-employed in any other role?
If yes, please provide details.
                                                                             Have you returned to normal work duties?
        Yes        No
                                                                                   Yes             No
                                                                             If yes, tell us the date you returned to normal duties. (dd/mm/yyyy)

                                                                             Have you been hospitalised for this condition?
                                                                                   Yes             No
                                                                             If yes, please make sure you provide us with a copy of the discharge
                                                                             summary from the hospital.
                                                                             1 If your name has changed and you work for the Queensland Government or related entity
                                                                             employer, let your payroll office know and they’ll then let us know. Otherwise, please send us
                                                                             a certified copy of either a marriage certificate or other legal change of name document.
2

Income Protection Benefit Claim (Part A) – Member Statement

                                                                          3 	Your job details and employment history

Please tell us your capacity to do the following activities:            Position/title
Can you dress yourself? (e.g. putting on and taking off clothes)
     Yes          No
                                                                        Please describe your job in detail, including all of your duties and
If no, please describe the help you need and how you’re limited.        responsibilities (and attach a position description and a copy of your
                                                                        resume if possible).

Can you bathe yourself? (e.g. washing and showering)
     Yes          No
Please describe the help you need and how you’re limited.

                                                                        If your job involves manual handling, please provide details of the types
Can you use the toilet by yourself, including getting on and off?       of items you might lift/push/pull/carry, the physical demand of these
                                                                        tasks and how often you do these tasks.
     Yes          No                                                    Lift (floor to waist)
Please describe the help you need and how you’re limited.

                                                                        Lift (knee to shoulder)
Are you mobile? (e.g. walking, getting in and out of a chair or bed)
     Yes          No
                                                                        Lift (waist to overhead)
Please describe the help you need and how you’re limited.

                                                                        Push/pull
Can you feed yourself? (e.g. getting food from a plate to your mouth)
     Yes          No
                                                                        Carry
Please describe the help you need and how you’re limited.

                                                                        What duties are/were you able to do?
Can you do housework? (e.g. cooking and cleaning)
     Yes          No
Please describe the help you need and how you’re limited.

Are you able to drive?                                                  What duties are/were you prevented from doing?
     Yes          No
If no, please provide details.

Do you take care of children or other dependants?                       What educational qualifications, degrees and/or certificates
                                                                        (including first aid and OHS) do you hold? Please include the year you
     Yes          No                                                    achieved these when providing details below.
Please describe your hobbies/interests/social activities.               Secondary school
                                                                        (e.g. year 10, year 12)
                                                                        Tertiary (university or
                                                                        technical college)

Does your condition affect your ability to do these activities?         Post-graduate
     Yes          No
                                                                        TAFE
If yes, please describe how you’re affected.
                                                                        Other

Please provide your treating doctor’s details below.
Name

Phone number

Email address
3

                                                                                   Income Protection Benefit Claim (Part A) – Member Statement

What specific work skills do you have (for example,                        Another insurance policy
management/supervision, retail, computer skills)?                          Income amount (gross)                 Frequency1
                                                                           $
Please give details of previous employment (approximate dates are fine).   Date payment started                  Date payments stopped
                                                                           (dd/mm/yyyy)                          (dd/mm/yyyy)
Position/title                       Employer

                                                                                                                 Date paid
Start date (dd/mm/yyyy)              End date (dd/mm/yyyy)                 Lump sum benefits                     (dd/mm/yyyy)
                                                                           $
Please describe all your duties and responsibilities.
                                                                           Pension Scheme
                                                                           Income amount (gross)                 Frequency1
                                                                           $
Position                             Employer                              Date payment started                  Date payments stopped
                                                                           (dd/mm/yyyy)                          (dd/mm/yyyy)

Start date (dd/mm/yyyy)              End date (dd/mm/yyyy)
                                                                                                                 Date paid
                                                                           Lump sum benefits                     (dd/mm/yyyy)
Please describe all your duties and responsibilities.                      $
                                                                           Other (please specify)
                                                                           Provide details of other sources of income which may include:
                                                                           motor accident compensation, Social Security, Statutory or other
If you’ve received an income from any of the sources we list below,        government payments.
please let us know the income, how often you receive it, the date
payment started and any lump sum payments below.                                                                 Date paid
                                                                           Lump sum benefits                     (dd/mm/yyyy)
Employer or business
Income amount (gross)                Frequency1                             $
 $                                                                         Income amount (gross)                 Frequency1
Date payment started                 Date payments stopped                 $
(dd/mm/yyyy)                         (dd/mm/yyyy)
                                                                           Date payment started                  Date payments stopped
                                                                           (dd/mm/yyyy)                          (dd/mm/yyyy)
                                     Date paid
Lump sum benefits                    (dd/mm/yyyy)
                                                                                                                 Date paid
 $                                                                         Lump sum benefits                     (dd/mm/yyyy)
Workers’ compensation                                                       $
Income amount (gross)                Frequency1
 $                                                                           4 	Other entitlements
Date payment started                 Date payments stopped
(dd/mm/yyyy)                         (dd/mm/yyyy)
                                                                           Have you claimed, or do you plan to claim, a benefit from WorkCover
                                                                           for this illness or injury?
                                     Date paid                                  Yes         No
Lump sum benefits                    (dd/mm/yyyy)
                                                                           Please tell us the start and end dates of the WorkCover claim period.
 $                                                                         Start date (dd/mm/yyyy)                End date (dd/mm/yyyy)
Department of Human Services
Income amount (gross)                Frequency1
                                                                           If you’re claiming WorkCover, please tell us your:
 $
                                                                           WorkCover case manager’s name
Date payment started                 Date payments stopped
(dd/mm/yyyy)                         (dd/mm/yyyy)
                                                                           WorkCover case manager’s
                                                                           phone number                          WorkCover claim number
                                     Date paid
Lump sum benefits                    (dd/mm/yyyy)
 $
1 Weekly, fortnightly, or monthly
4

Income Protection Benefit Claim (Part A) – Member Statement

    5 	Details of earnings before your illness or injury                  7    Receiving your payment
        (complete this section if you don’t work for
                                                                         We can only make payments into an Australian bank, credit union
        the Queensland Government)                                       or building society account that’s in your name or a joint name
                                                                         This means we can’t make payments into a business, trust or loan
What was your income (gross) prior to your                               account.
illness or injury?                                 $
What was your base salary (gross) prior to your                          You should know that if you provide incorrect details, there could
illness or injury?                                 $                     be a delay in your payment or a loss of interest, and we can’t
                                                                         accept responsibility for this.
Please provide details of your packaged salary below. (including base
salary, fees, and regular bonuses, allowances, overtime earnings and     Name of bank, credit union or building society
commissions)

                                                                         Branch (BSB) number                Account number

    6 	Please complete if you’re self-employed
                                                                         Account name
What income did your business earn in the last 12 months, as a direct
result of your physical exertion or activity through usual occupation?
                                                                         Signature
Gross income from occupation                       $
Expenses                                           $
                                                                         Date (dd/mm/yyyy)
What were your income and expenses for the last 12 months
(pre-disability)?
Gross income from occupation                       $
Expenses                                           $
What were your income and expenses for the last 24 months
(pre-disability)?
Gross income from occupation                       $
Expenses                                           $
5

                                                                                                         Income Protection Benefit Claim (Part A) – Member Statement

    8 	Declaration and authorisation

•    I’m the person named on this form or have power of attorney                                  I agree that the individuals and organisations listed below can have
     to act on the member’s behalf.1                                                              access to my personal and medical information so that they can
•    I confirm the information provided in this form is true and                                  investigate and assess my claim:
     correct, and I haven’t withheld any information that’s relevant                              •   Workers’ compensation
     to my claim.
                                                                                                  •   CTP insurer
•    I agree to provide all medical information and undertake any
                                                                                                  •   Federal and State Government agencies including the
     medical or occupational assessments requested by QSuper.
                                                                                                      Department of Human Services and the Department of
•    I understand I can’t receive an income protection benefit from                                   Veterans’ Affairs
     QSuper and compensation from WorkCover for the same
                                                                                                  •   my employer (only with my written consent)
     period.
                                                                                                  •   my accountant
•    I understand that if I am granted compensation from
     WorkCover for the same period, I may be asked to pay back                                    •   my doctors, specialists and their agents
     QSuper the income protection benefits paid to me during                                      •   QSuper
     that time.                                                                                   •   QSuper’s insurers
•    I authorise any insurer (including workers’ compensation/CTP                                 •   QSuper’s appointed assessor which may be located overseas in
     insurer), government agencies (including the Department of                                       North America or the European Union.
     Human Services and the Department of Veterans’ Affairs), my
     employer, accountant or other relevant holder of information                                 Name
     to release to QSuper or its insurers2 information they might
     need to assess my claim.
•    I understand that a photocopy of my authority is considered as                               Signature
     valid as the original.
•    I authorise QSuper to refer to any statements that have been
     made in connection with my application for insurance and
     any medical reports to other entities involved in providing or                               Date (dd/mm/yyyy)
     administering my insurance (for example reinsurers, third party
     administration or specialist claims providers and legal advisers)
     or persons appointed to obtain financial, employment or
     medical related information in support of the assessment of                                      If we need to contact you about this form, tell us which
     my claims from any other entity holding information on me.                                       way you’d prefer to be contacted?
•    I consent to any sensitive information such as medical
     information collected in this form being used by the QSuper                                          Mobile            Home phone            Email
     Board and its insurers1 and any of its authorised service
     providers for the purposes of assessing my eligibility for
     personalised cover and for the assessment or investigation of
     any future claims made in relation to such cover.
•    I have read QSuper’s Your Privacy factsheet and I understand
     how QSuper will collect, use and disclose my personal
     information to relevant to this claim.

1 If you’re signing as a power of attorney and you haven’t already given us a certified copy of
your power of attorney documentation, please attach it to this form.
2 QSuper’s insurers include TAL Life Limited, QInsure, OnePath and Suncorp.
6

        Income Protection Benefit Claim (Part A) – Member Statement

        Checklist
        Make sure you use this checklist to check you’ve completed the
        claim form and you have all the supporting documents ready to
        send us.

        I’ve provided all the relevant information in section 1.
              Yes            No

        I’ve provided details on my condition in section 2 and attached
        copies of any medical evidence I already have on my condition
        (and any other relevant information).
              Yes            No

        I’ve completed my job details and employment history in section 3
        (and section 5 for non-Queensland Government employees).
              Yes            No

        If I’m claiming any other entitlements, I’ve provided details in
        section 4.
              Yes            No

        I’ve signed the QSuper declaration in section 7.
              Yes            No

        I’ve provided details of my bank account in section 7 and
        have attached a copy of my bank, credit union or building
        society statement.
              Yes            No

        I’ve provided a completed Tax File Number Declaration form.
              Yes            No

             The information you’ve provided will be used to assess your
             benefit entitlement for insurance. You should keep a copy
             of your completed form and this guide as you may want to
             refer to it in the future.

             Where do I send the form?
             Once you’ve completed the form and attached any
             necessary documents, send it to us at QSuper, Insurance
             Operations, GPO Box 200, Brisbane Qld 4001.

            Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane                         Postal address GPO Box 200 Brisbane Qld 4001                       ABN 60 905 115 063
            Telephone 1300 360 750 (+617 3239 1004 if overseas)                                           Fax 1300 242 070                                                   SFN 261041941
            Monday to Thursday 8:30am to 5:00pm AEST                                                      Website qsuper.qld.gov.au                                          CNC-1135 01/18 IB29
            Friday 9:00am to 5:00pm AEST

This form and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). We take the privacy of your personal information very
seriously. We’re collecting personal information from you so we are able to assess your claim and are authorised to do this under the Superannuation (State Public Sector) Act 1990. We may also
collect information from your employer, government agencies, other superannuation funds, anyone you authorise and if it is required or authorised by law. We may disclose your information to
your employer, authorised service providers (including QInsure Limited ABN 79 607 345 853 AFSL 483057 and any of its authorised service providers), other superannuation funds and government
agencies and to third parties if we need to, if you’ve given consent to the disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet
from our website or call us on 1300 360 750 and request a copy. The information outlined in this form is general information only and doesn’t take into account your personal objectives, financial
situation, or needs. Before you make any decision regarding a QSuper product you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy.
© QSuper Board 2018
QSuper Form                                                                                                                         1

Income Protection Benefit Claim
(Part B) – Employer’s Statement
Who needs to complete this form?
This section of the claim form needs to be completed by your employer (HR or payroll office staff). Please ensure all questions are answered
before you send it to us.

  1       Employee information                                                 3     Employment information
Title         Given names                                                    Does your employee work:

                                                                                   Full time
Surname
                                                                                   Part-time                       p/t fortnightly ratio

                                                                                   Casual
Date of birth (dd/mm/yyyy)          Payroll number
                                                                                   Contractor                      contract end date (dd/mm/yyyy)
Position/job title                                                           When did your employee last attend work? (dd/mm/yyyy)

Place of employment and region                                               When did they start sick leave? (dd/mm/yyyy)

                                                                             What date was all accrued sick leave exhausted? (dd/mm/yyyy)

  2 	Salary information
                                                                             Has your employee received other paid leave since all accrued sick
                                                                             leave was exhausted?
What was your employee’s full time salary at 1 July before they went
on sick leave without pay (SLWOP)?                                                 Yes          No
Date (dd/mm/yyyy)                   Salary                                   If yes, what date does this cease?
 1 July 20                           $                 per fortnight

What was your employee’s full time salary prior to starting sick leave?      Employer rehabilitation contact name
Date (dd/mm/yyyy)                 Salary

                                     $                 per fortnight         Phone number

Salary: When you provide your employee’s salary, it needs to
be their remunerated salary upon which the superannuation                    Email address
contribution is calculated.
If your employee works part-time, please provide us with their
full-time salary and indicate the part-time ratio in section 3.              Preferred method of contact?
What was the employer paid Superannuation Guarantee                                Email        Phone
Contribution (SGC) rate for your employee?
                                                                             Who else, apart from employer rehabilitation contact above, should
                               %                                             be advised upon assessment of claim?
Is your employee paying child support?                                       Name/s
        Yes        No
                                                                             Position/Job Title                   Phone number

                                                                             Email address
2

        Income Protection Benefit Claim (Part B) – Employer’s Statement

            4 	Additional comments                                                                       Additional information about this form
        Please supply any information that clarifies or supports this                                     As the employer, you need to complete this employer’s
        Employer’s Statement.                                                                             statement for any employee who is covered by QSuper’s income
                                                                                                          protection insurance.
                                                                                                          Please ensure you complete all the sections in the employer’s
                                                                                                          statement before returning to QSuper promptly.
                                                                                                          This will assist QSuper to progress the assessment of your
                                                                                                          employee’s claim for an income protection benefit.
                                                                                                          If your employee’s situation changes, it is important you let us
                                                                                                          know straight away. This includes changing the type of leave they
                                                                                                          take, if they start working again, or their employment is terminated.
                                                                                                          Please call us on 1300 360 750 or email us at
                                                                                                          insuranceclaims@qsuper.qld.gov.au to let us know.

            5    Employer information
                                                                                                                Where to send the completed form?
        Name of employer                                                                                        Once you have completed this form you can:
                                                                                                                Email us at insuranceclaims@qsuper.qld.gov.au

        Full name of authorised officer

        Position held

        Phone number

        Email address (not generic email address)

        Date completed (dd/mm/yyyy)

            Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane                         Postal address GPO Box 200 Brisbane Qld 4001                       ABN 60 905 115 063
            Telephone 1300 360 750 (+617 3239 1004 if overseas)                                           Fax 1300 242 070                                                   SFN 261041941
            Monday to Thursday 8:30am to 5:00pm AEST                                                      Website qsuper.qld.gov.au                                          CNC-1135 01/18 IB29
            Friday 9:00am to 5:00pm AEST

This form and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). We take the privacy of your personal information very
seriously. We’re collecting personal information from you so we are able to assess your claim and are authorised to do this under the Superannuation (State Public Sector) Act 1990. We may also
collect information from your employer, government agencies, other superannuation funds, anyone you authorise and if it is required or authorised by law. We may disclose your information to
your employer, authorised service providers (including QInsure Limited ABN 79 607 345 853 AFSL 483057 and any of its authorised service providers), other superannuation funds and government
agencies and to third parties if we need to, if you’ve given consent to the disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet
from our website or call us on 1300 360 750 and request a copy. The information outlined in this form is general information only and doesn’t take into account your personal objectives, financial
situation, or needs. Before you make any decision regarding a QSuper product you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy.
© QSuper Board 2018
QSuper Form                                                                           Please complete in block letters, in blue or black ink.
                                                                                                                                                         1

Income Protection Benefit Claim
(Part C) – Doctor’s Statement
Who needs to complete this form?
Your doctor needs to complete this part of the claim form. We need detailed information from them about your illness or injury before we can
pay you an income protection benefit. Remember you need to cover any costs your doctor charges to complete this form.
Also be sure to check out the Additional info about this form on page 5 to make sure you have all the info you need.

  1       Claimant’s details (your patient)
Title         Given names                                                  If yes, please provide the contact details of the doctor they first saw
                                                                           and the consultation date.
                                                                           Name
Surname

                                                                           Specialty
Date of birth (dd/mm/yyyy)              Height (cm)        Weight (kg)

                                                                           Date of consultation (dd/mm/yyyy)

  2 	Treating medical practitioner (completing                            Who diagnosed the patient’s condition?

          this form)
                                                                           Based on your objective clinical findings, please confirm the
Name                                                                       patient’s diagnosis.

Specialty                               Practice                           Please describe your objective findings that support the
                                                                           diagnosis (for example, if the diagnosis relates to a mental
                                                                           illness, please provide criteria as per DSMIV)
Phone number

Email address

Postal address
                                                                           If the diagnosis relates to a musculoskeletal condition, please
                                                                           provide any details on ROM, strength testing, neurological
                                                                           testing and any other special tests.

                                State              Postcode

Are you this patient’s usual general practitioner?
        Yes        No
If yes, what date did you first begin treating this patient?
(dd/mm/yyyy)                                                               If the diagnosis relates to a cardiac condition, please indicate the
                                                                           patient’s cardiac functional capacity:

Did this patient see any other doctors before they first consulted         Class 1 – No limitations
you?
                                                                           Class 2 – Slight limitations
        Yes        No
                                                                           Class 3 – Marked limitations

                                                                           Class 4 – Severe limitations

                                                                           If your objective findings have changed since the initial
                                                                           diagnosis, please tell us any updated findings.
2

Income Protection Benefit Claim (Part C) – Doctor’s Statement

    3 	Medical History                                               4 	Treatment and progress of the illness
                                                                            or injury
Please outline the patient’s initial symptoms relating to this      What active treatment (such as physiotherapy, surgery, counselling,
condition.                                                          medication) has the patient received from you and other practitioners
                                                                    since their illness or injury was diagnosed?
                                                                    Nature of treatment

                                                                    Date referred
When did the patient’s symptoms for this condition first start or
occur? (dd/mm/yyyy)
                                                                    Frequency of treatment

Have the patient’s symptoms changed in frequency or severity?
                                                                    Effectiveness of treatment
     Yes          No
If yes, please describe how.
                                                                    Medication

                                                                    Dosage/frequency
Has the patient ever experienced these symptoms, or similar
symptoms, previously?
     Yes          No                                                Date prescribed

If yes, from when? (dd/mm/yyyy)
                                                                    Effectiveness of medication

If yes, please provide details.
                                                                    Is there any additional treatment that would help improve the
                                                                    patient’s functional capacity that they mightn’t be able to access due
                                                                    to a lack of financial resources or other reasons?
                                                                         Yes          No
                                                                    If yes, please provide details.

                                                                    What tests or investigations have been done to date and what
                                                                    were the results of these tests?

                                                                    Please attach copies of test results where applicable (e.g. MRI, CT
                                                                    scan, x-ray, ultrasound, blood/urine tests, ECG)
3

                                                                                Income Protection Benefit Claim (Part C) – Doctor’s Statement

                                                                          5 	Your patient’s capacity to work

How often are you seeing the patient at this time? When is their next   What is your understanding of the patient’s occupation and their
appointment?                                                            duties?

Has your patient been referred to any consultants or specialists?       Is the patient currently working?

     Yes          No                                                         Yes, part-time           Yes, full-time         No

If yes, please provide the consultant/specialist’s contact details.     If yes, how many hours are they working per week?

Name
                                                                        If no, how do the symptoms of their illness or injury stop them from
                                                                        working?
Practice

Postal address

                                                                        From what date was your patient unable to work due to the injury or
                                                                        illness? (dd/mm/yyyy)
                                State             Postcode
Phone number                                                            Please outline any specific medically supported restrictions and/or
                                                                        limitations that would need to be considered to help the patient return
                                                                        to work.
Date of first appointment (dd/mm/yyyy)                                  Restriction and/or limitation 1
                                                                        Functional capacity impacted e.g. lifting, sitting
Do you believe the patient has reached maximum medical
improvement (MMI)?
     Yes          No                                                    Restriction and/or limitation

If yes, please explain below.

                                                                        Are these considered permanent?
                                                                            Temporary               Permanent
                                                                        If temporary, what’s the expected timeframe of the restrictions and/or
                                                                        limitations?

                                                                        Current capacity e.g. 30kg, 30 minutes

                                                                        Restriction and/or limitation 2
                                                                        Functional capacity impacted e.g. lifting, sitting

                                                                        Restriction and/or limitation

                                                                        Are these considered permanent?
                                                                            Temporary               Permanent
                                                                        If temporary, what’s the expected timeframe of the restrictions and/or
                                                                        limitations?

                                                                        Current capacity e.g. 30kg, 30 minutes
4

Income Protection Benefit Claim (Part C) – Doctor’s Statement

Restriction and/or limitation 3                                          Restriction and/or limitation 5
Functional capacity impacted e.g. lifting, sitting                       Functional capacity impacted e.g. lifting, sitting

Restriction and/or limitation                                            Restriction and/or limitation

Are these considered permanent?                                          Are these considered permanent?
    Temporary               Permanent                                         Temporary               Permanent
If temporary, what’s the expected timeframe of the restrictions and/or   If temporary, what’s the expected timeframe of the restrictions and/or
limitations?                                                             limitations?

Current capacity e.g. 30kg, 30 minutes                                   Current capacity e.g. 30kg, 30 minutes

Restriction and/or limitation 4                                          Are there any specific or temporary workplace changes that could
                                                                         help the patient return to work? Please outline below.
Functional capacity impacted e.g. lifting, sitting

Restriction and/or limitation

                                                                         Are there any medical barriers to the patient returning to work within
Are these considered permanent?                                          the restrictions/limitations outlined above?
    Temporary               Permanent                                         Yes          No
If temporary, what’s the expected timeframe of the restrictions and/or   If yes, please provide details below.
limitations?

                                                                         If the patient isn’t responding to treatment or there are delays
Current capacity e.g. 30kg, 30 minutes                                   in accessing treatment, would you appreciate input from an
                                                                         independent medical specialist?
                                                                              Yes          No
5

                                                                                                            Income Protection Benefit Claim (Part C) – Doctor’s Statement

  6 	Declaration

The information I’ve provided in this form is true and correct at the
time of completion.
Name

Signature

Date (dd/mm/yyyy)

Additional info about this form
Make sure you complete your section of the claim form in full so
the patient’s claim isn’t delayed.
If you’d like to know more about our privacy policy,
download QSuper’s Your Privacy factsheet on our website at
qsuper.qld.gov.au

     Where do I send the form?
     Once you’ve completed the form and attached any
     necessary documents, send it to us at QSuper, Insurance
     Operations, GPO Box 200, Brisbane Qld 4001.

            Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane                 Postal address GPO Box 200 Brisbane Qld 4001                               ABN 60 905 115 063
            Telephone 1300 360 750 (+617 3239 1004 if overseas)                                   Fax 1300 242 070                                                           SFN 261041941
            Monday to Thursday 8:30am to 5:00pm AEST                                              Website qsuper.qld.gov.au                                                  CNC-1135 01/18 IB29
            Friday 9:00am to 5:00pm AEST

This form and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). We take the privacy of your personal information very
seriously. We’re collecting personal information from you so we are able to assess your claim and are authorised to do this under the Superannuation (State Public Sector) Act 1990. We may also
collect information from your employer, government agencies, other superannuation funds, anyone you authorise and if it is required or authorised by law. We may disclose your information to
your employer, authorised service providers (including QInsure Limited ABN 79 607 345 853 AFSL 483057 and any of its authorised service providers), other superannuation funds and government
agencies and to third parties if we need to, if you’ve given consent to the disclosure, or if we’re required to by law. If you want to know more you can download QSuper’s Your Privacy factsheet
from our website or call us on 1300 360 750 and request a copy. The information outlined in this form is general information only and doesn’t take into account your personal objectives, financial
situation, or needs. Before you make any decision regarding a QSuper product you should consider the PDS, which you can download at qsuper.qld.gov.au, or call us on 1300 360 750 for a copy.
© QSuper Board 2018
Member Centres 70 Eagle Street Brisbane and 63 George Street Brisbane                        Postal address GPO Box 200 Brisbane Qld 4001                             ABN: 60 905 115 063
           Telephone 1300 360 750 (+617 3239 1004 if overseas)                                          Fax 1300 242 070                                                         SFN: 2610 419 41
           Monday to Thursday 8:30am to 5:00pm AEST                                                     Website qsuper.qld.gov.au                                                CNC-1135 01/18 IB29
           Friday 9:00am to 5:00pm AEST

This guide and all products are issued by the QSuper Board (ABN 32 125 059 006 AFSL 489650) as trustee for QSuper (ABN 60 905 115 063). The information provided is general information only and
doesn’t take into account your personal objectives, financial situation, or needs. You should consider whether the product is appropriate for you by reading the product disclosure statement (PDS) and
consider seeking financial advice before making a decision. You can get a copy of the PDS by downloading a copy from our website at qsuper.qld.gov.au or call us on 1300 360 750. © QSuper Board 2018
You can also read
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