CRITICAL ILLNESS CLAIM FORM

CRITICAL ILLNESS CLAIM FORM
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
Full 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 Name
Bank Number
Branch
Branch Number
Account Number:
Account Name
Swift Code (Overseas account only)
Bank Address(overseas account only)
4| Critical Illness:
Doctors declaration of Critical Illness
- For a Critical Illness claim, this section must be completed by Cook Islands Ministry of Health Medical Practitioner.
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 Cook Islands Ministry of Health Medical Practitioner.
- Based on my assessment or diagnosis of the above-named Member and/or my review of the relevant medical evidence provided, I certify that applicable statement below to the extent that I am professionally able to verify it. Where I was not the referring or treating practitioner, my certification is based on the medical evidence available to me and does not constitute endorsement of, or responsibility for, the orginal referral or treatment decision.
- Where the Member requires specialist treatment outside the Cook Islands. I certifythat the member suffers from a Critical Illness that requires specialist treatment which is not available in the Cook Islands.
- Where the Member has already received specialist treatement outside the Cook Islands. I certify that the Member suffered from a Critical Illness at the time the specialist treatment was received and that the treatment was not available in the Cook Islands.
- I have attached, where applicable, relevant medical reports supporting medical evidence relating to the Member's condition and treatment.
IMPORTANT NOTICE:

Medical certification supports the Member's application but does not determine entitlement to a Benefit. Eligibility and payment of any Benefit are determined by the Trustee in accordance with the Trust Deed.
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

DayMonthYear
2 digit day, 2 digit month, 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

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CRITICAL ILLNESS CLAIM FORM

Section 1: Member Details:

2| Withdrawal Request:

3| Payment Details

4| Critical Illness:

5| AUTHORISED APPLICANT DETAILS

6|Member Declaration Member Declaration

7|Checklist