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Before you sign this form please be aware that Macquarie Life Limited ABN 56 003 963 773 AFSL 237 497 (MLL) is obliged to have provided you with a Product Disclosure Statement dated 15 June 2010 containing a summary of the important information relating to this product. This information will help you to decide whether the product is appropriate for your needs. To secure your cover, complete this form and submit by 29 February 2012. If you have any questions, please call us on 1800 111 393.

 Details of First Person
Title Initials Given Names Surname
Address
Date of Birth(dd/mm/yyyy) Telephone - Day Telephone - Evening Member Number
Male Female Have you smoked any tobacco in the past 12 months? Yes No
Tick as appropriate
How much funeral cover would you like? $3000 $5000 $7500 $10000 $15000
Monthly premium: 
Cover only available for ages 50 to 65. Please call 1 800 111 393 for further information
premium_male_smokers $0.00 $0.00 $0.00 $0.00 $0.00
If you wish to name a beneficiary, please give their details below (one beneficiary only please)

Full name of beneficiary Relationship to you

Beneficiary Address

Before you sign this form please be aware that Macquarie Life Limited ABN 56 003 963 773 AFSL 237 497 (MLL) is obliged to have provided you with a Product Disclosure Statement dated 15 June 2010 containing a summary of the important information relating to this product. This information will help you to decide whether the product is appropriate for your needs. To secure your cover, complete this form and submit by 29 February 2012. If you have any questions, please call us on 1800 111 393.

Details of Second Person
Title Initials Given Names Surname
Address
Date of Birth(dd/mm/yyyy) Telephone - Day Telephone - Evening Member Number
Male Female                                       Have you smoked any tobacco in the past 12 months? Yes No
Tick as appropriate
How much funeral cover would you like? $3000 $5000 $7500 $10000 $15000
Monthly premium: 
Cover only available for ages 50 to 65. Please call 1 800 111 393 for further information
premium_male_smokers $0.00 $0.00 $0.00 $0.00 $0.00
If you wish to name a beneficiary, please give their details below (one beneficiary only please)

Full name of beneficiary Relationship to you

Beneficiary Address

Please tick how you wish to pay your premiums.
Monthly from your bank or financial institution account
I/we request Macquarie Life (User ID 145096) to debit my nominated account through the Bulk Electronic Clearing System (BECS) any amounts that become payable in relation to my National Seniors Funeral Plan Policy.
I/we agree to the terms outlined in the Direct Debit Service Agreement, a copy of which will be sent to me with my Policy Document, or is available on request by calling 1800 111 393.
Name of Financial Institution
BSB Number  
Account Number
Account Name
Monthly by credit card
Yearly by credit card
I authorise the debit of monthly or annual National Seniors Funeral Plan premiums to my credit card account detailed below.
Visa Mastercard
Card Number
Card Expiry (mm/yy) /
Name on Card

Please read and accept below
Please issue a National Seniors Funeral Plan as indicated above. I understand that cover will become effective when a completed acceptance form is received and processed by Macquarie Life Limited prior to the close date of 29 February 2012. I also understand that a policy document and schedule will be sent to me and that I will have 30 days to review and to cancel the policy with a full refund of any premiums paid if I am not completely satisfied. I acknowledge that I have been given the Product Disclosure Statement (PDS) dated 15 June 2010 and that my decision to accept this insurance is based on the information contained in the PDS. I acknowledge that I have not been given any personal financial product advice by Macquarie Life Limited and that, by not receiving such personal financial product advice, I risk making a financial commitment to an insurance policy that may or may not be appropriate to my needs and objectives.

I declare that the details included on this form are correct. I agree that my personal information can be collected, used and disclosed by Macquarie Life Limited and their agents in accordance with the “Your privacy” statement contained in the PDS and authorise Macquarie Life Limited to debit my premiums from either my credit card or through the Direct Debit System, according to whichever authorisation I have completed above.
 
First Person:
I(enter full name)   accept the terms and conditions.
                        Date  
Second Person:
I(enter full name)   accept the terms and conditions.
                        Date