CSC AFSL 238069 RSEL L0001397 ABN 48 882 817 2431922 Scheme

CSS RSE R1004649 ABN 19 415 776 361

DFRB Scheme

MilitarySuper RSE R1000306 ABN 50 925 523 120

DFRDB Scheme ABN 39 798 362 763

PSS RSE R1004595 ABN 74 172 177 893

PNG Scheme

PSSap RSE R1004601 ABN 65 127 917 725

DFSPB

Commonwealth Superannuation Corporation (CSC) ABN: 48 882 817 243, AFSL: 238069, RSEL: L0001397 Defence Force Retirement and Death Benefits SchemeABN: 39 798 362 763

Australian Defence Force SuperannuationABN: 90 302 247 344 RSE: R1077063

Commonwealth Superannuation SchemeABN: 19 415 776 361 RSE: R1004649

Public Sector Superannuation accumulation planABN: 65 127 917 725 RSE: R1004601

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

Australian Defence Force CoverABN: 64 250 674 722

Public Sector Superannuation SchemeABN: 74 172 177 893 RSE: R1004595

1922 Scheme DFRB Scheme PNG Scheme DFSPB CSC retirement income

PSSap Application for issue of invalidity retirement certificate

SPC-PSSap11/18

FOR EMPLOYER

USE

A Member’s detailsPSSap member number

Title Mr Mrs Ms Miss Other

Surname

Given name(s)

Date of birth We cannot issue an invalidity retirement certificate to PSSap customers over age 60

D D M M Y Y Y Y

/ /

Address

SUBURB STATE POSTCODE

PhoneBUSINESS HOURS AFTER HOURS

MOBILE NUMBER

All sections to be completed by Employer.

We’re committed to protecting your privacy. We collect your personal information for the purposes of providing superannuation services to you, improving our products and keeping 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 csc.gov.au/privacy/

Your privacy is important to us

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Email

@

B Employer’s detailsEmployer’s name

Employer’s address

SUBURB STATE POSTCODE

Case manager surname

Case manager given name(s)

Email

@

Payroll officer

C Employment and superannuation detailsDate on which employment started

D D M M Y Y Y Y

/ /

Date member started leave for a continuous period because of a serious medical condition

D D M M Y Y Y Y

/ /

Is member in receipt of compensation benefits in respect of the current condition?

Yes No

Has member applied for compensation benefits?

Yes No

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EmailCSS and PSS: employer.service@admin.csc.gov.auPSSap: employers@pssap.com.au

PhoneCSS and PSS: 1300 338 240PSSap: 1300 308 806

FaxCSS and PSS: (02) 6272 9996PSSap: 1300 364 144

Web eac.csc.gov.au

Fax(02) 6272 9613

Emailemployer.service@csc.gov.au

Phone1300 338 240

PostPSSapLocked Bag 9300Wollongong NSW 2500Web

csc.gov.auOverseas Callers+61 2 4298 6030

End Form

D Checklist of attachments to this form Sick leave records Duty statement Reports from at least two registered medical practitioners dated within the last 12 months Employee’s resume Any other medical reports or documentation, such as rehabilitation reports, graduated return to work programs, etc Documents related to compensable conditions (e.g. Comcare decisions or medical reports)

E Declaration by case manager I certify that the above information is correct and that the member has been provided with information about

invalidity retirement.

SIGNATUREDate signed

D D M M Y Y Y Y

/ /

Send this completed application form with the documents listed in Section D to claims@pssap.com.au

Sign

Where can I get more information?EMAIL employer.service@csc.gov.auPHONE 1300 338 240MAIL PSSap

Locked Bag 9300 Wollongong NSW 2500

WEB csc.gov.au

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