Application to Join the Universities of New Zealand Staff Voluntary Plan

  • Please answer the following questions and complete the application below.
  • Once completed please e-mail the form to for a premium illustration

At Work declaration:

I hereby declare that to the best of my knowledge;

  1. Have you been diagnosed with a terminal illness, or have you received medical advice that you have an illness or condition that is likely to result in your death within 12 months of the date of this application (with or without treatment), Yes No
  2. Have you been absent from work due to injury or illness, for 10 or more consecutive days in the 90 days immediately before the date of signing this form? Yes No
  3. Are you *actively at work or available for work and not restricted by sickness or illness from performing all of your normal duties of paid permanent employment?Yes No
  4. Have worked for less than 30 days at the university? Yes No

(Please note that if you are on a fixed term contract your contract duration must be 2 years or more at date of applying for cover)

  1. At the date of this application do you work 15 hours or more per week at the university

Yes No

Date of application ………../………../…………

*actively employed means that you are not prevented by accident or sickness from properly performing your normal duties of paid permanent employment. For the sake of clarity, permanent employment means that you have an individual agreement of either indefinite duration, or for a fixed term, with the employer requiring you to perform identifiable duties for a regular number of hours of no less than 15 hours each week.

You are actively employed on the date that you apply or would have been had the relevant day not been a public holiday, weekend day or a day of leave other than due to accident or sickness; and has not been absent from work for 10 continuous days or more due to sickness or accident in the past 90 days.

Please provide the following information to enable us to process an accurate premium.

Name of University
Your name
Date commenced work at the university
Your occupation
Your address
Your phone number
Your date of birth
Gender / Male Female
Your annual base salary / $
Have you smoked in the past 12 months / Yes No

Please indicate your preference for cover

Life insurance
Three times your base salary
This cover can be taken on its own but is mandatory if you join the plan / Yes
$ / No
Income Protection Insurance
75% of yourannual base salary
Waiting period 90 days
Five year benefit
Must be taken with life cover / Yes
$ / No
Living Assurance
Three times your base salary but limited to a maximum of $50,000 cover
Must be taken with life cover / Yes
$ / No

Please feel free to call Mercer Marsh Benefitson any matter related to the plan on 0800 467 637.

Marsh Ltd, Level 18, 151 Queen St, Auckland.

E-mail to