The information provided in this document is general advice only and has been prepared without taking account of your personal objectives, financial situation or needs. Before acting on any such general advice, you should consider the appropriateness of the advice, having regard to your own objectives, financial situation and needs. You may wish to consult a licensed financial advisor. You should obtain a copy of the PSS Product Disclosure Statement (PDS) and consider its contents before making any decision regarding your super.Commonwealth Superannuation Corporation (CSC) ABN: 48 882 817 243 AFSL: 238069 RSEL: L0001397 Trustee of the Public Sector Superannuation Scheme (PSS) ABN: 74 172 177 893 RSE: R1004595

Important information about this form Use this form to continue your Additional Death and Invalidity Cover (ADIC) if you are going on approved leave without pay (LWOP). The information in Section B is required by AIA Australia to determine if they will continue to underwrite your cover. Upon approval, you will be required to pay both the member and employer share of the premiums for the period of leave. These premiums will count towards your non-concessional contributions cap.Please note that exclusions apply and no benefits are payable for death or injury as a result of war or active service.If your circumstances change after you have lodged this form, you will need to complete a new form. For further information call 1300 000 377.

How to use this formPlease use CAPITAL LETTERS and a black or blue pen.Mark boxes like this with a or then fill out the next question or section.

A Personal detailsReference number (AGS)

Title Mr Mrs Ms Miss Other

Surname

Given name(s)

Date of birthD D M M Y Y Y Y

/ /

Address

SUBURB STATE POSTCODE

SE805/19

ADIC application to continue while on leave without pay

Section A continued on next page

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PhoneBUSINESS HOURS AFTER HOURS

MOBILE NUMBER

Email (Please provide an email address, other than work, where you can be contacted while on LWOP.)

@

B LWOP detailsLeave from

D D M M Y Y Y Y D D M M Y Y Y Y

/ / to / /

Note: if your LWOP will exceed the expected end date (above), you will need to apply (and be approved) for an extension (by completing and resubmitting this form to us) with your new date. If you do not reapply, your cover will cease 30 days after the expected end date.

Reason for LWOP if greater than 24 months.

For example: travelling overseas, studying, caring for a family member, accompanying spouse on overseas posting.

What will be your residential address while on LWOP?

SUBURB STATE POSTCODE

What will be your postal address while on LWOP? If same as residential address, write ‘AS ABOVE’.

SUBURB STATE POSTCODE

C DeclarationI declare that:• the information I have provided on this form is complete and correct• I understand I am responsible for and must pay both the member and employer share of the

premium while on LWOP, and that these premiums will count towards my non-concessional contributions cap.

• I have read and understood the Death and Invalidity booklet available at csc.gov.au• I understand that if I lodge a claim while residing overseas, AIA Australia may require me to return

to Australia for the duration of my claim.

SIGNATUREDate signed

D D M M Y Y Y Y

/ /Sign

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Emailmembers@pss.gov.au

Phone1300 000 377

Financial Advice1300 277 777

PostPSSGPO Box 2252Canberra ACT 2601Web

csc.gov.auOverseas Callers+61 6192 9505

Fax(02) 6275 7010

D LodgementYou have now completed this form. Please send your completed form to us: Post: PSS ADIC

GPO Box 2252 Canberra ACT 2601 AUSTRALIA

Email: formsandapplications@csc.gov.au Fax: 02 6275 7010

PrivacyPersonal information that you or a third party provide, such as your employer, is collected, held, used and disclosed as required or authorised by law in accordance with our privacy policies and notice for the purpose of managing your super. This includes the administration of your account and insurance cover. Your information will be passed on to our insurer, AIA Australia, for the same purpose and AIA Australia may make it available to medical practitioners to establish your insurance coverage or if you lodge a claim.The privacy policies and notice are available via csc.gov.au and aia.com.au or by contacting us on 1300 000 377. The privacy policies and notice contain important information about how personal information is handled, including rights to access and update that information and how a complaint about a breach of privacy can be made.

Need assistance? Call us on the phone numbers below

End Form

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