• Total and Permanent Disability Claim Form

    For Members Under Age 55

  • BEFORE YOU BEGIN

  • Use this form to apply for a Total and Permanent Disability (TPD) benefit from the Cook Islands National Superannuation Fund (CINSF).

    You may be eligible for a Total and Permanent Disability benefit if, before the age of 55, you become totally and permanently disabled due to injury or illness.

    For the purposes of this claim, Total and Permanent Disablement means that: you have been absent from employment because of injury or illness for 6 consecutive months; and as a result of that injury or illness, you have become incapacitated to such an extent that you are unlikely ever to engage in paid employment in any occupation or work for which you are reasonably qualified by education. Your claim must be supported by medical evidence confirming your condition, the period of incapacity, and your future capacity for employment.

    All claims are subject to the eligibility requirements of the CINSF Trust Deed and the required approval process.

  • SECTION 1 Member details

  • Title*
  • Date of birth (DD/MM/YYYY)*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Gender*
  •  -
  •  -
  • Last date worked (DD/MM/YYYY)*
     - -
    2 digit day, 2 digit month, 4 digit year
  • Final payroll contribution date (DD/MM/YYYY)*
     - -
    2 digit day, 2 digit month, 4 digit year

  • SECTION 2 Payment details

  • SECTION 3 Medical certification

  • To be completed and signed by the treating medical practitioner. The claim cannot be processed without this declaration and the supporting medical reports.
  • CINSF
  • Date the member became unable to work due to the injury or illness (DD / MM / YYYY)
     - -
    2 digit day, 2 digit month, 4 digit year

  • Medical practitioner declaration. I confirm that:

  • 2. In my professional opinion, the patient's injury or illness has prevented them from engaging in employment for at least 6 consecutive months.
    3. In my professional opinion, the patient's incapacity is total and permanent to such an extent that the patient is unlikely ever to engage in employment for reward in any occupation or work for which they are reasonably qualified by education.
    4. I have attached relevant medical reports and supporting information concerning the patient's diagnosis, treatment, incapacity and prognosis.
  • Date (DD / MM / YYYY)
     - -
    2 digit day, 2 digit month, 4 digit year

  • SECTION 4 Member declaration and signature

  • Please read the statement carefully before signing.

    By signing this form, I confirm that:
    a) The information and supporting documents I have provided are true, complete and correct to the best of my knowledge.
    b) I understand that eligibility for a Total and Permanent Disability benefit is subject to the requirements of the CINSF Trust Deed and the required approval process.
    c) I understand that the percentage of my Compulsory Account payable is determined by my age on the date I make this claim.
    d) I understand that my account balances remain subject to investment gains and losses until my claim is approved and processed.
    e) I authorise CINSF to verify the information provided in this form and to obtain information reasonably necessary to assess and process my claim, including information from my employer and treating medical practitioner.
    f) I understand that providing false or misleading information may result in delays, recovery of any overpayment, or other action in accordance with the CINSF Trust Deed, Fund Rules or applicable law.

  • Date (DD/MM/YYYY)
     - -
    2 digit day, 2 digit month, 4 digit year

  • SECTION 5 Required information and documents

  • CINSF cannot process your claim until all required information and supporting documents have been provided. Tick each item to confirm it is attached.

  • A. COMPLETED CLAIM FORM

  • B. IDENTIFICATION

  • Provide one valid form of photo identification:
  • C. MEDICAL EVIDENCE

  • D. EMPLOYER CONFIRMATION

  • Provide an employer letter confirming:

  • E. BANK ACCOUNT CONFIRMATION

  • Provide one document confirming the bank account stated in Section 2:
  • Cook Islands National Superannuation Fund
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  • Submit in person, by email to enquiry@superfund.gov.ck, or by post to PO Box 3076, Avarua, Rarotonga
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