Investment Growth Bond Application Form

This document is the application form for an Investment Growth Bond. It provides instructions and fields to be completed by the applicant(s) and includes sections for personal details, investment options, automatic withdrawal facility details, adviser service fees, and more.

Before you sign this Application, you must read the Product Disclosure Statement
(PDS) dated 18 March 2013. The PDS will help you to understand the product and
decide whether it’s appropriate to your needs. Policy No:
Office Use Only
The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA)
CommInsure is a registered business name of CMLA
• All Applicants need to complete this section.
• If there is more than one Applicant, they will own the policy as joint tenants.
• If the Applicant is a child between 10 and 16 years old then please ensure Section 4 is completed.
• If this Application is a Child Advancement Policy then please ensure both Sections 2 and 3 are completed.
Section 1 - Applicant(s) details
Please write in BLOCK letters and use a black ballpoint pen.
Fields marked with an asterisk (*) must be completed for the purposes of Anti-Money Laundering and Counter-Terrorism Fin
In this Application, ‘you’ and ‘I/we’ refers to the proposed Applicant(s) or Life/Lives Insured or both as indicated.
CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AF003-886 010813 (BRC25)
Page 1 of 6
Investment Growth Bond
Application Form
Is the investor an individual?
Yes NoComplete below or Go to Company, Fund or Trust details on page 21
Bond Owner 1 (‘Applicant 1’)
Surname* Surname*
Other names known by (if any)* Other names known by (if any)*
For sole trader, full business name* (where applicable) For sole trader, full business name* (where applicable)
Given name(s)* Given name(s)*
Date of birth* Date of birth*
Residential/Business address* (PO Box is not acceptable) Residential/Business address* (PO Box is not acceptable)
Mailing address Mailing address
Home phone number Work phone number
Mobile Facsimile
Email address
Home phone number Work phone number
Mobile Facsimile
Email address
Gender
Female Male
Gender
Female Male
Bond Owner 2 (‘Applicant 2’)
Your main country of residence, if not Australia*
Occupation*
Is the investor a resident of Australia?* No Yes
Your main country of residence, if not Australia*
Occupation*
Is the investor a resident of Australia?* No Yes
For sole traders, ABN (if any)* For sole traders, ABN (if any)*
State Postcode Country State Postcode Country
State Postcode Country State Postcode Country
1. For Company, Fund or Trust applications, please complete the appropriate Anti-Money Laundering and Counter Terrorism Financing form that can be
downloaded from commbank.com.au/igb or contact us on 1800 624 100 to request a copy
OtherMr Ms Mrs Miss OtherMr Ms Mrs Miss
Do you wish to receive marketing material? NoYes Do you wish to receive marketing material? NoYes
✔
✔
BAKER DENNIS
LOT 3 WATTLE ROAD, HURSTBRIDGE, VICTORIA
VIC 4165 Australia
23/07/1966 ✔
BUSINESS DEVELOPMENT MANAGER
✔
✔
( ) ( )
( )
✔
BAKER DONNA
LOT 3 WATTLE ROAD, HURSTBRIDGE, VICTORIA
VIC 4165 Australia
15/07/1965 ✔
JOINER
✔
✔
( ) ( )
( )

Section 2 - Life/lives insured
The Investment Growth Bond is a life insurance policy. For child advancement policies the child must be listed as the life ins
only one life insured may be nominated.
Bond Owner 1 (‘Applicant 1’) continued Bond Owner 2 (‘Applicant 2’) continued
Investor – Company, Fund or Trust1 Investor – Company, Fund or Trust1
Company/Fund/Trust name* Company/Fund/Trust name*
Type of Investor* Type of Investor*
Company Fund Trust Company Fund Trust
Principal business/trust activity* Principal business/trust activity*
Country established, if not Australia* Country established, if not Australia*
Phone numberPhone numberABN* ABN*
Are you a charity?* No Yes Are you a charity?* No Yes
CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AF003-886 010813 (BRC25)
Page 2 of 6
Business address* (PO Box is not acceptable) Business address* (PO Box is not acceptable)
Mailing address Mailing address
State Postcode Country State Postcode Country
State Postcode Country State Postcode Country
Life Insured 1 Life Insured 2
Surname Surname
Other names known by (if any) Other names known by (if any)
Given name(s) Given name(s)
Home phone number Home phone numberWork phone number Work phone number
Mobile MobileFacsimile Facsimile
Email address Email address
The Life/Lives insured cannot be altered once the policy has commenced.
The Death Benefit Guarantee is based on the death of the life/lives insured not the Bond owner(s).
Residential address* (PO Box is not acceptable) Residential address* (PO Box is not acceptable)
Mailing address Mailing address
State Postcode Country State Postcode Country
State Postcode Country State Postcode Country
1. For Company, Fund or Trust applications, please complete the appropriate Anti-Money Laundering and Counter Terrorism Financing form that can be
downloaded from commbank.com.au/igb or contact us on 1800 624 100 to request a copy
OtherMr Ms Mrs Miss OtherMr Ms Mrs Miss
Date of birth* Date of birth*Gender
Female Male
Gender
Female Male
Do you wish to receive marketing material? NoYes Do you wish to receive marketing material? NoYes
✔
CommInsure Adviser
( )
✔
CommInsure Adviser
( )
✔
BAKER DENNIS
LOT 3 WATTLE ROAD, HURSTBRIDGE, VICTORIA
VIC 4165 Australia
23/07/1966 ✔
( ) ( )
( )
✔
BAKER DONNA
LOT 3 WATTLE ROAD, HURSTBRIDGE, VICTORIA
VIC 4165 Australia
15/07/1965 ✔
( ) ( )
( )

Section 5 - Investment options (Funds)
Minimum is $200 per Fund. The minimum initial investment is $1,000. Cash deposits will not be accepted.
Cheque (Please attach with this form, made payable to “CMLA - Investment Growth Bond”)
Bpay® (Important: Please refer to page 15 of the PDS before using Bpay®. If this is your initial investment then we will contact your
financial adviser (or you, if you do not have a financial adviser) and provide our BPAY® Biller Code and your unique Customer
Reference Number (CRN).
® Registered to Bpay Pty Ltd ABN 69 079 137 518
Investment option Amount
NC – Cash (3NCS) $
NC – Global Fixed Interest (3NFI) $
NC – Conservative (3NCO) $
NC – Diversified (3NDI) $
NC – Balanced (3NBA) $
NC – Growth (3NGR) $
NC – Global Property (3NPR) $
NC – Australian Shares (3NAU) $
NC – International Shares (3NIN) $
Please indicate (✔) how will you be paying
CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AF003-886 010813 (BRC25)
Page 3 of 6
Complete this section if you wish to set up a Child Advancement Policy and the child is under 16 years old.
Please note, only one child may be nominated as the Life Insured and only one Bond Owner can apply.
The Bond Owner should also provide details in Section 1.
I declare that the Policy issued on the basis of this Application on the life of
shall be a Child Advancement Policy in accordance with the provisions of the Life Insurance Act 1995 and on the child’s (10th – 25th)
birthday shall become the absolute property of the child (please note where no vesting age is nominated, the tr
occur when the child turns 25).
Date
Signature of Bond Owner
✗
Date of birth
Section 3 - Child advancement policy
This consent is not required for a Child Advancement Policy.
This section must be completed by the parent/guardian if the Bond Owner is age 10 or more, but less than age 16.
I,
as a parent/guardian of
hereby consent to this Application on the life of
Section 4 - Parental/Guardian consent statement
Signature of parent(s)/guardian(s)
Date
Signature of parent/guardian 1
✗
Signature of parent/guardian 2
✗
<select>

Section 6 - Automatic withdrawal facility details
or
Complete this section if you will be investing at least $10,000 and you wish to arrange for regular payments from your investm
% of the value of units at each date (if less
than $500, no amount will be withdrawn)
$Amount of each payment (minimum $500)
First withdrawal date
Last withdrawal date (if required)
Frequency
Monthly Quarterly YearlyHalf-yearly
Please complete the banking details to enable funds to be
deposited into an account.
Note: we will not pay automatic regular withdrawals by cheque.
Name of financial institution
BSB (Branch number) Account number
Rate of increase in payments
orNil % each year
Account name (must be in the name of the Bond Owner(s))
Section 7 - Adviser service fee(s)
Complete this section if you consent for CMLA to pay your adviser(s) a one-off and/or an ongoing adviser service fee.
One-off adviser service fee
I/We consent for CMLA to deduct a one-off adviser service fee of$ (please specify the total dollar amount)
on (insert date)*. Any payments to financial advisers are in accordance with the arrangements we have
their dealer group. My financial adviser(s) and allocations are noted below.
Name of financial adviser Allocation of dollar amount**
1.
2.
* If this date is prior to the commencement of the policy, we will deduct the one-off adviser service fee one day after the
commencement date.
** Only required if the payment is to be split between two financial advisers
The amount nominated above should be deducted from my chosen investment options as follows:
Investment option One-off adviser service fee
NC – Cash (3NCS) $
NC – Global Fixed Interest (3NFI) $
NC – Conservative (3NCO) $
NC – Diversified (3NDI) $
NC – Balanced (3NBA) $
NC – Growth (3NGR) $
NC – Global Property (3NPR) $
NC – Australian Shares (3NAU) $
NC – International Shares (3NIN) $
Please note: where you do not indicate which investment option(s) the one-off adviser service fee is to be paid from, the a
will be deducted on a pro-rata basis.
Ongoing adviser service fee
I/We consent for CMLA to deduct an ongoing adviser service fee (as nominated below). Any payments to financial advisers a
accordance with the arrangements we have with their dealer group. My financial adviser(s) and allocations are noted below
Name of financial adviser Allocation of dollar or percentage amount*
1.
2.
* Only required if the payment is to be split between two financial advisers
The fixed or percentage amount should be deducted from my investment options as follows:
Investment option Fixed amount to be paid monthly ($)or Percentage amount (% p.a.)
NC – Cash (3NCS) $ %
NC – Global Fixed Interest (3NFI) $ %
NC – Conservative (3NCO) $ %
NC – Diversified (3NDI) $ %
NC – Balanced (3NBA) $ %
NC – Growth (3NGR) $ %
NC – Global Property (3NPR) $ %
NC – Australian Shares (3NAU) $ %
NC – International Shares (3NIN) $ %
CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AF003-886 010813 (BRC25)
Page 4 of 6

Name of financial adviser 1 Name of financial adviser 2
Financial adviser number AFSL number Financial adviser number AFSL number
Company name of financial adviser (if applicable) Company name of financial adviser (if applicable)
Contact name Contact name
Telephone work Mobile Telephone work Mobile
Facsimile Facsimile
Section 8 - Financial adviser use only
Customer Contact
No YesIf required, do you give us permission to contact the Bond Owner(s) direct to clarify any necessary matter?
I certify that I have provided the Bond Owner(s) with the Investment Growth Bond PDS with a preparation date of 18 Mar
I certify that the adviser sections of the relevant Identification and Verification form for all Bond Owner(s) have been com
Where any Adviser Service Fee(s) have been noted in Section 7, I certify that I am able to set up this Adviser Service Fee
with the Bond Owner(s) and that they have agreed to this arrangement and that I have read and understood page 19 of
(Adviser Service Fees).
Financial adviser declaration
✗
Signature of financial adviser 1 Date
✗
Signature of financial adviser 2 Date
Please note: all advisers to sign.
Please read the terms and conditions below carefully before following the eProcess instructions outlined.
eProcess instructions:
1. Complete all relevant sections of the Application form in the PDS, dated 18 March 2013.
2. Gather all required documentation, including the completed application form, identification and verification schedule, an
documentation requested. Refer to the checklist on page 32 of the PDS.
3. Fax all documents to CommInsure Administration on 1300 852 094. No cover sheet is required OR
4. Scan all documents and attach the file to an email addressed to [e-mail]. The subject line shou
“New application for <insert clients name>.”
5. Retain the original Application documents in your client file.
Depositing the initial investment via direct credit
When investing with ordinary money, the initial investment can be directly deposited into CommInsure Investment Growth
account instead of posting a cheque.
Instructions:
1. Deposit the investment into the following bank account:
Account name: CMLA # 1 account, BSB: 062 000, Account number: 1085 2246
2. Request a receipt for the deposit.
3. Attach a copy of the deposit receipt.
*Please note we do not direct debit funds from a client’s bank account.
By using the eProcess, I (the Advisers named in Section 8 of this Application) agree to the following additional terms and co
1. Originals of all documents sent via the eProcess must be retained by me and be made available to CommInsure upon re
2. Documents sent to the nominated fax number are said to be received by CommInsure on the date that they have a reco
received the documents. However if the fax is received after 5pm on a normal business day, the fax will not be regarded
received until the next normal business day. I also understand that where CommInsure has no record of receiving a docu
may mean that I will have to recommence the application process.
3. Documents sent to the nominated email address are said to be received by CommInsure on the date we have a record o
an acknowledgement back to you that the application has been received. While CommInsure does not guarantee this pro
it is our usual business process to send a response indicating that we have received the documents the same day that ou
administration staff view your email to our nominated email inbox. However if your original email is received after 5pm o
business day then we will not view the email until the next business day.
The following requirements apply to deposits into the CommInsure Investment Growth Bond bank account
4. If you have banked the full amount in relation to the Application into the bank account nominated by CommInsure, you m
a copy of the deposit receipt.
5. You must bank the full amount in relation to any application into the nominated bank account. Partial payments will mea
application process will not be able to commence until we have reconciled such payments.
6. If a payment is made into any bank account other than the one nominated by CommInsure above, CommInsure will not
accountable for any financial losses incurred.
eProcess Terms and Conditions
Lodging an Application for a CommInsure Investment Growth Bond via eProcess (fax or email)
003-886 010813 (BRC25) CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 APage 5 of 6
( )
( )
( )
( )

I/We wish to apply to CMLA for the life insurance policy detailed in this Application.
I/We have read and understood:
• The Investment Growth Bond PDS. My/Our decision to apply for this policy is based on the material received and my/ou
the information included in the PDS; and
• My/Our ‘Duty of Disclosure’ in Section 9 of this Application. I am/we are aware of the consequences of non-disclosure. I/W
my/our duty to disclose continues after I/we have completed this Application until CMLA has accepted the Application for insuran
I/We declare that:
• The answers to all questions and declarations on this Application are true and correct including those not in my/our ow
• All the information/documentation required under the Anti-Money Laundering and Counter-Terrorism Financing laws ha
• The answers given, together with any special conditions, will form the basis of the contract; and
• No information has been withheld which may affect CMLA’s decision to provide insurance.
I/We understand that:
• The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AFSL 235035 (CMLA) is a wholly owned sub
Commonwealth Bank of Australia ABN 48 123 123 124.
• The Bank and its subsidiaries (except to the extent expressly stated otherwise in the PDS) do not guarantee the per
the Investment Growth Bond or the repayment of capital or earnings by CMLA. Investments in the Bond are not deposits o
liabilities of the Bank or its subsidiaries (other than CMLA), and investment-type products are subject to investment risk in
loss of income and principal invested.
• I have read and understood the section ‘Privacy of your personal information’ on page 30 of the PDS. I acknowledge
the use and disclosure of my personal information as detailed in that section.
• I declare that if this Application is signed under a Power of Attorney, the Attorney declares that they have not receiv
that power (Note: a certified copy of the Power of Attorney should be submitted with the Application. This must be accom
by information/documentation required under Anti-Money Laundering and Counter Terrorism Financing laws for both the P
Attorney and the Bond Owner(s)).
• The policy will not commence until CMLA accepts this application in writing, receives the first contribution and issues a
• I/We have read page 19 of the PDS concerning the Adviser Service Fee and consent for CMLA to deduct the Adviser
indicated in this Application Form.
Section 10 - Declaration
Position in company (if Bond Owner 1 is a company) Position in company (if Bond Owner 2 is a company)
If the Applicant is a company then this must be signed by an authorised officer (e.g. Director, Company Secretary).
✗
Signature of Bond Owner 1 Date
✗
Signature of Bond Owner 2 Date
✗
Signature of Life Insured 1 Date
✗
Signature of Life Insured 2 Date
Mail this application to:
Investment Growth Bond - Life New Business
PO Box 320, Silverwater NSW 2128
Section 9 - Duty of disclosure
Before you enter into or become insured under a contract of life insurance with an insurer, you have a duty under the Insura
Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, that is
to the insurer’s decision whether to accept the risk of insurance, and if so, on what terms.
You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of lif
Your duty, however, does not require disclosure of a matter:
• That diminishes the risk to be undertaken by the insurer;
• That is of common knowledge;
• That your insurer knows or, in the ordinary course of its business, ought to know; or
• As to which compliance with your duty is waived by the insurer.
Non disclosure
If you fail to comply with your Duty of Disclosure and the insurer would not have covered you on any terms if the failure had not
insurer may avoid your cover within 3 years of issuing it. If your non-disclosure is fraudulent, the insurer may avoid your cover a
An insurer who has not avoided your cover within 3 years of issuing it may elect to reduce the sum that you have been insure
with a formula that takes into account the premium that would have been payable if you had disclosed all relevant matters to
CommInsure is a registered business name of The Colonial Mutual Life Assurance Society Limited ABN 12 004 021 809 AF003-886 010813 (BRC25)
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