Commonwealth Superannuation Corporation (CSC) ABN: 48 882 817 243, AFSL: 238069, RSEL: L0001397 Australian Defence Force SuperannuationABN: 90 302 247 344 RSE: R1077063

Military Superannuation and Benefits SchemeABN: 50 925 523 120 RSE: R1000306

Australian Defence Force CoverABN: 64 250 674 722

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Any advice provided in this form is general advice only and has been prepared without taking account of your personal objectives, financial situation or needs. Before acting on any such general advice, you should consider the appropriateness of the advice, having regard to your own objectives, financial situation and needs. You may wish to consult a licensed financial advisor. You should obtain a copy of the relevant Product Disclosure Statement (PDS) and consider its contents before making any decision regarding your super.

Who should use this form? Use this form if you satisfy the following:• you were formerly a contributing member of MilitarySuper

or a covered ADF member under ADF Coverand• you retired from the Defence Force for reasons other than

invalidity or medical dischargeand• you are seeking to apply to be treated as if you had

retired from the Defence Force for reasons of invalidity or medical discharge.

After completing this form, please forward it to CSC at the address shown in Part F of this form.

Application for retrospective invalidity

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Before you use this form If you are applying for retrospective

invalidity as a MilitarySuper member, you must have a MilitarySuper preserved employer benefit.

Other eligibility requirements apply for retrospective invalidity under ADF cover.

Please contact our Customer Information Centre (CIC) on 1300 006 727 (for MSBS members) or 1300 001 977 (for ADF Cover members) to confirm you are eligible to

apply or for any other information that you require. Before completing this form, it is recommended

that you read the MilitarySuper Product Disclosure Statement (PDS) found on the CSC website

csc.gov.au or the information found at csc.gov.au/Members/Insurance-and-cover/

Invalidity/adf-super/

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What is retrospective invalidity?Rule 30 of the Military Superannuation and Benefits Act 1991 and section 31A of the Australian Defence Force Cover Act 2015 allows Commonwealth Superannuation Corporation (CSC) to consider whether former ADF members who retired for reasons other than invalidity or medical discharge, may be treated as though they had retired from the Defence Force on invalidity grounds or had been medically discharged, respectively.

Meeting the criteriaBefore it can approve an application, CSC must be satisfied that grounds existed on which the applicant could have been retired on the ground of invalidity (for MilitarySuper) or medically discharged because of a physical or mental impairment (for ADF Cover), having regard to all relevant circumstances. We will consider any medical evidence provided by an applicant, however, as we are determining whether grounds could have existed at the time of the applicant’s discharge from the Defence Force, evidence from at or around that time will carry the most weight.To assist us in making a decision under either rule 30 or section 31A, CSC may request a full copy of the applicant’s in–service medical file from the Department of Defence and a full copy of the applicant’s file from the Department of Veterans’ Affairs (DVA). Please note, however, that any claims for by the applicant that have been accepted by DVA, will not necessarily be assessed as part of the applicant’s MilitarySuper or ADF Cover retrospective invalidity claim. In some circumstances CSC may refer a retrospective invalidity application to the Department of Defence’s Joint Health Command (JHC) for an opinion, however an opinion of JHC is not binding on CSC.

Completing this formComplete:• Part A: About yourself• Part B: Reasons for requesting retrospective invalidity• Part C: Department of Defence – Authority to provide medical and employment records• Part D: DVA and/or Military Rehabilitation and Compensation Commission (MRCC) – Authority to

provide information • Part E: DeclarationPlease refer to csc.gov.au and then lodge with CSC at the address in Part F.

Authority FormsIn order to assist the investigation of your claim, could you please complete the authority forms at Parts C and D which will allow us to seek information, if necessary, from your medical practitioner, employer, the Department of Defence, DVA or MRCC as required.

Do you have a personal representative?If you have a representative you would like to act on your behalf, please complete the Third Party Authority (AUTH-MSB) form available at csc.gov.au, or provide a written signed authority for your representative to act on your behalf.

PrivacyWe’re committed to protecting your privacy. We collect your personal information for the purposes of providing superannuation services to you, improve our products and to keep you informed. We will only share your personal information where necessary for providing superannuation services to you. This may include disclosing your personal information to our scheme administrator, service providers or government or regulatory bodies. Your personal information may be accessed overseas by our service providers. Please see our privacy policy for full details. Your personal information will not be otherwise used or disclosed unless required or permitted under law. A full copy of our privacy policy as well as the privacy complaint process is available at www.csc.gov.au/privacy/

You do not need to return this page with your form

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Commonwealth Superannuation Corporation (CSC) ABN: 48 882 817 243, AFSL: 238069, RSEL: L0001397 Australian Defence Force SuperannuationABN: 90 302 247 344 RSE: R1077063

Military Superannuation and Benefits SchemeABN: 50 925 523 120 RSE: R1000306

Australian Defence Force CoverABN: 64 250 674 722

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Application for retrospective invalidity

A About Yourself1. Service Navy Army RAAF

Service number/ Employee ID

2. Title Mr Mrs Ms Miss Other

Surname

Given name(s)

3. Date of birthD D M M Y Y Y Y

/ /

4. Residential address

SUBURB STATE POSTCODE

Postal address

SUBURB STATE POSTCODE

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B Reasons for requesting retrospective invalidity5. Please provide details about why you are seeking retrospective invalidity, including the grounds on which you believe

that you could have:• been retired from the Defence Force by reason of invalidity (for Military Super); or• been medically discharged from the Defence Force by reason of a physical or mental impairment. All medical conditions or impairments are assessed as at the date of your discharge. Please provide any supporting medical evidence you may have regarding the claimed conditions or impairments. If you need additional space, please attach additional pages/documents to this form.

5. Contact detailsBUSINESS HOURS AFTER HOURS

MOBILE NUMBER

E-mail

@

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C Department of Defence – Authority to provide medical and employment records7. Service number/

Employee ID

I, GIVEN NAME(S)

SURNAME

ofRESIDENTIAL ADDRESS

SUBURB STATE POSTCODE

authorise the Department of Defence to make available to Commonwealth Superannuation Corporation (CSC) on presentation of a copy of this authority, full records relating to my employment, training and medical history (including clinical notes and psychological records) in respect of my Defence Force service and/or advice in respect of such employment, training and medical history.I also authorise CSC to release copies of the documents obtained under this authority to appropriate medical advisers where such release is necessary for the administration of the Military Superannuation and Benefits Act 1991 and/or the Australian Defence Force Cover Act 2015.I understand that, whilst the information will be subject to standard confidentiality requirements, CSC may be obliged, under the legislative provisions that have application to it, to release the information provided, in whole or in part, to a tribunal or Court. The information to be collected on the basis of this authorisation is for a lawful purpose which is necessary for, or directly related to, the administration of Military Superannuation and Benefits (MSB) Act 1991 and/or the Australian Defence Force Cover Act 2015.I understand that any information collected under this authorisation may be liable to release to other Australian Government agencies in accordance with the disclosure provisions of the Australian Privacy Principles contained in the Privacy Act 1988, in particular, to those agencies (such as the Department of Veterans’ Affairs) concerned with the provision of financial benefits which may be affected by my entitlements under the Military Superannuation and Benefits (MSB) Act 1991 and/or the Australian Defence Force Cover Act 2015.This authorisation is to remain in force until revoked by me in writing.

Signature and date SIGNATUREDate signed

D D M M Y Y Y Y

/ /

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D Department of Veterans’ Affairs (DVA) and/or MilitarySuper Rehabilitationand Compensation Commission (MRCC) – Authority to provide information8. DVA/MRCC

reference number

I, GIVEN NAME(S)

SURNAME

ofRESIDENTIAL ADDRESS

SUBURB STATE POSTCODE

authorise the Department of Veterans’ Affairs (DVA) and/or the Military Rehabilitation and Compensation Commission (MRCC) to make available to Commonwealth Superannuation Corporation (CSC) on presentation of a copy of this authority, any medical reports, determinations, correspondence and other records and/or advice pertinent to those matters which they may request from time to time for the purpose of administering the Military Superannuation and Benefits Act 1991 and/or the Australian Defence Force Cover Act 2015.I also authorise CSC to release copies of the documents obtained under this authority to its medical advisers where such release is necessary for the administration of the abovementioned legislation.I understand that, whilst the information will be subject to standard confidentiality requirements, CSC may be obliged, under the legislative provisions that have application to it, to release the information provided, in whole or in part, to a tribunal or Court.This authorisation is to remain in force until revoked by me in writing.The information to be collected on the basis of this authorisation is for a lawful purpose which is necessary for, or directly related to, the administration of Military Superannuation and Benefits (MSB) Act 1991 and/or the Australian Defence Force Cover Act 2015.I understand that any information collected under this authorisation may be liable to release to other Australian Government agencies in accordance with the disclosure provisions of the Australian Privacy Principles contained in the Privacy Act 1988, in particular, to those agencies (such as the Department of Veterans’ Affairs) concerned with the provision of financial benefits which may be affected by my entitlements under the Military Superannuation and Benefits (MSB) Act 1991 and/or the Australian Defence Force Cover Act 2015.

Signature and date SIGNATUREDate signed

D D M M Y Y Y Y

/ /

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EMAIL members@adfcover.gov.au PHONE 1300 001 977 FAX (02) 6275 7010 MAIL ADF Cover GPO Box 2252 Canberra ACT 2601 WEB csc.gov.au

EMAIL members@enq.militarysuper.gov.au PHONE 1300 006 727 FAX (02) 6275 7010 MAIL MilitarySuper GPO Box 2252 Canberra Act 2601 WEB csc.gov.au

E Declaration9. I declare that:

• the information I have provided is true and correct to the best of my knowledge• I acknowledge that it may be a criminal offence to knowingly provide false or misleading

information or documents• I have read the MilitarySuper PDS found on the CSC website csc.gov.au or the information

found at csc.gov.au/Members/Insurance-and-cover/Invalidity/adf-super/ and I understand the options available for my benefit entitlement

• I understand that if I have not completed all the required information, this application may be returned to me for completion and payment may be delayed.

Signature and date SIGNATUREDate signed

D D M M Y Y Y Y

/ /

I do not want my contact details passed to a commissioned independent research firm for the purpose of participating in research on the service provided by CSC.

F Lodgement10. Post your completed original application and attachments to:

Commonwealth Superannuation Corporation GPO Box 2252 Canberra ACT 2601

11. Email your completed application form and attachments to formsandapplications@csc.gov.au

Where can I get more information?If you need help completing this form or you need further information about the retrospective process, please contact us using the details below.Please note: the Military Superannuation and Benefits Act 1991 and Australian Defence Force Cover Act 2015 are different to legislation administered by DVA.

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