CRITICAL ILLNESS CLAIM FORM

CRITICAL ILLNESS CLAIM FORM
Use this form to apply for a withdrawal from your Cook Islands Superannuation Fund account upon approval as a referred patient.
Important Information
PLEASE READ THIS SECTION BEFORE YOU START COMPLETING THIS FORM. Use this form to apply for a withdrawal from your CINSF account upon approval as a referred patient.

Important Information

Under the provisions of the Trust Deed, as a Member, you may be able to make a withdrawal from the Cook Islands National Superannuation Fund if you are suffering a Critical Illness as defined in the Trust Deed. The withdrawal of savings from CINSF in the case of Critical Illness is subject to the Trustee's Approval.

Critical Illness as defined in the Trust Deed, means an injury or illness that a Cook Islands Ministry of Health Medical Practitioner has determined by assessment or diagnosis that such injury or illness requires a member to obtain specialist treatment that is not available in the Cook Islands.

Pensioners are not entitled to this benefit.
Section 1: Member Details:
RMD Number
NSF Number
Title

Other
Name

First NameLast Name
Date of birth (DD/MM/ YY)

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Age
Gender:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Country CodePhone Number
Mobile Phone

Country CodePhone Number
Email
example@example.com
2| Withdrawal Request:
You can elect to receive a benefit in a single lump sum or claim a lesser amount and claim at a future time provided the combined total of the claim does not exceed $5,000
Amount of withdrawal

3| Payment Details
If your application is approved, which bank account would you like payments to be made into?
Bank
Bank Number
Branch
Branch Number
Account Number:
Account Name
Swift Code (Overseas account only)
Bank Address(overseas account only)
4| Critical Illness:
For a Critical Illness:
- ask your doctor to submit a doctors form declarating below:
DOCTOR'S DECLARATION OF CRITICAL ILLNESS PATIENT
PATIENT Full Name

First NameLast Name
Address
DOCTOR
I, Doctor
of
Address
Island/City/State/Country
Daytime Number

Country CodePhone Number
Mobile

Country CodePhone Number
Email Address
example@example.com
Confirm that:
- I am a registered medical practitioner with the Cook Islands Medical Council and Dental Council or with an equivalent registration regime outside the Cook Islands.
- The above-named is a patient of mine whom I have recently conducted a full medical examination and in my opinion, has a Critical illness that poses a serious and imminent risk of death.
- The above-named has within the last 90days returned from overseas following a medical procedure requiring specialist treatment unavailable in the Cook Islands.
- To support this claim please find attached the patient's medical report(s) along with confirmation of the TMO referral letter.
Signature of Medical Practitioner
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate

5| AUTHORISED APPLICANT DETAILS
Applicant Name
Relationship to Member
Residential Address
Home Phone

Country CodePhone Number
Mobile Number

Country CodePhone Number
Email Address
example@example.com
Applicant Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
6|Member Declaration Member Declaration
By completing this form, I understand and confirm.
I. That I meet the requirements to qualify for the critical illness benefits.
II. The Funds received from this claim are strictly to provide me with financial assistance due to my medical referral overseas.
III. The information provided on this form is clear and all the answers provided by me are true and correct.
IV. I hereby indemnify the CINSF Board and Trustee from any liability whatsoever, including any loss of benefits that may arise as a result of approving my applications.
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
7|Checklist
Make sure to send us everything listed below, as we can't consider your request without the following.Before CINSF can process your claim, please ensure you submit ALL the following documents.
You can email this form, and all required supporting documents to enquiry@superfund.gov.ck

Upload Required Documents

Cancelof
Should be Empty:

CRITICAL ILLNESS CLAIM FORM

Important Information

Section 1: Member Details:

2| Withdrawal Request:

3| Payment Details

4| Critical Illness:

5| AUTHORISED APPLICANT DETAILS

6|Member Declaration Member Declaration

7|Checklist