TERMINAL ILLNESS BENEFIT FOR PENSIONER FULL PAYMENT REQUEST

TERMINAL ILLNESS BENEFIT FOR PENSIONER FULL PAYMENT REQUEST
PLEASE READ THIS SECTION BEFORE YOU START COMPLETING THIS FORM. The Trustee will only authorise payment of your Terminal Illness benefit if, after considering relevant medical evidence, it considers you are suffering an illness that poses a serious and imminent risk of death.
1. Member details - Cook Islands National Superannuation Fund
RMD Number
CINSF Member Number
Title
First name(s)
Surname
Residential Address
Home Phone

Country CodePhone Number
Mobile Phone

Country CodePhone Number
Email Address
example@example.com
Gender
Date of Birth (DD/MM/YY)

DayMonthYear
Date
Final contribution date

DayMonthYear
Date
Step 2 - Payment Details:
Payment Options
Email: enquiry@superfund.gov.ck Phone: +682 25515 PO Box 3076, Avarua Rarotonga, Cook Islands WWW.CINSF.COM

Step 3- Terminal Illness for Pensioners:
For a Terminal Illness full payout:
- ask your doctor to complete the declaration below.
DOCTOR'S DECLARATION OF TERMINAL ILLNESS FOR PENSIONERS
PATIENT
Full Name

First NameLast Name
Address
DOCTOR
I, Doctor
of

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Number
Format: (000) 000-0000.
Email Address
example@example.com
Certify that:
- I am registered medical practitioner with the Medical Council of the Cook Islands or with an equivalent registration regime outside the Cook Islands.
- the above-named is a patient of mine and I have recently given them a full medical examination.
- In my opinion, the above named has a terminal illness that poses a serious and imminent risk of death
Please find attach a medical report(s) with a brief description of the patient's condition:
Signature of Medical Practitioner
Date

MonthDayYear
Date
Step 4 - Declaration
I certify that the information I have provided on this form is true and correct.
Signature
Date

MonthDayYear
Date
Should be Empty: