Data capture form

Transcription

Data capture form

Friends Life Protect+
Data capture for online personal cover,
business cover and tele-interviewing
FLIP/5441/Oct14
This form is not an application form, but is intended to help advisers gather information from their clients before submitting it on behalf of
their client using the Friends Life Individual Protection Online Application System or for online submission for the tele-interviewing
service.
Do not send this form to Friends Life Individual Protection.
It will not be accepted as an application form.
We cannot accept business online if the applicant is not resident in the United Kingdom.
This form is provided solely to assist advisers in collecting information to submit to Friends Life Individual Protection online.
Friends Life Individual Protection accepts no responsibility that the information submitted to it by the adviser for their client
online matches the information in this form and it is the adviser’s obligation (acting for their client) to ensure the information
submitted to Friends Life Individual Protection by the adviser for their client is accurate.
2 |
FAILURE TO DISCLOSE RELEVANT INFORMATION IN RESPONSE TO QUESTIONS ASKED MAY
RESULT IN NON-PAYMENT OF A CLAIM
Introduction
Notes
•You should explain to your client that the information supplied here by your client in response to the questions in this form, together
with any other information in response to any other questions subsequently asked of your client in respect of their application, will form
part of the application that you submit electronically to Friends Life Individual Protection. It is important that your client responds
truthfully and completely to all the questions they are asked. If your client is in any doubt as to whether particular information should
be disclosed they should disclose it. Failure to reply accurately and completely to the questions in this form and in the online
application and to any other questions asked of your client by you or by Friends Life Individual Protection with regard to the online
application you are making on behalf of your client may result in the non-payment of a claim and may also result in the cancellation of
your client’s policy in certain specific circumstances (please see the Protect+ Membership Handbook for further information).
•
Please ensure that your client responds truthfully and completely to all the questions they are asked with regard to their application.
Please ensure that your client informs us of any changes to their answers to the questions in this form and to any other questions you
or Friends Life Individual Protection ask your client with regard to this application including those on the online application which you
are making on behalf of your client. We need to know of any changes which would have resulted in different replies by your client to
questions asked either:
• on or resulting from the application form or other questionnaire; or
• by any doctor or nurse acting on our behalf.
Changes to your client’s responses would include having or expecting to have a doctor, hospital or clinic consultations, treatment as an
in-patient or a blood test for any reason. We also need to know immediately of any changes to responses regarding your client’s occupation
or to responses regarding hazardous sports or pastimes before cover starts.
If we are advised of any changes to your client’s responses we will confirm in writing whether or not any terms quoted will still apply.
• We may ask your client to contact their doctor if we are waiting for reports, which we have asked for.
•If we ask your client to attend a medical examination, we will need to share the application information with any company we authorise
to conduct such examinations. They will make the arrangements for the examination to take place.
•We may need to send your client’s application and relevant medical reports to our reassurers for their opinion or agreement of the
terms offered.
Or, we may need to send them at a later stage for purposes relating to managing the policy.
You should ensure that when using the online application process you comply at all times with the Terms of Business agreed between
your firm and Friends Life Individual Protection.
Medical evidence
•Please remind your client that if there is nothing disclosed in their personal or family history to require it, we will not usually obtain a
report from their General Practitioner or need a medical examination unless the sum assured exceeds specific levels based on age.
•Please remind your customer that, even if we do request a report from their doctor, they must still answer all questions with regard to
the online application you are making on their behalf as fully and accurately as possible.
Tele-interviewing
Please note that an application cannot be submitted for tele-interviewing if either the life assured has been diagnosed with, or
suffered from cancer, heart disease, stroke, multiple sclerosis or diabetes within the last two years or has been unsuccessful in
applying for life, critical illness or income protection cover within the last two years.
• Please ensure you provide your client(s) with a tele-interview client leaflet in advance of submitting their application online.
• Please ensure that your client answers questions in sections 1, 2, 3, 4, 5, 8, 14 and 15 only.
• Please note that if the application is for joint life cover, both lives will be tele-interviewed.
• Please ensure your client(s) sign the declaration(s) in section 13.
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The data capture form
The form is made up of the following sections:
1
About lives assured............................................................................................................................................................................................................................... 5
2
About schemeholders.......................................................................................................................................................................................................................... 5
Quote details...................................................................................................................................................................................................................................................6-9
3
Existing cover.........................................................................................................................................................................................................................................10
4Occupation...............................................................................................................................................................................................................................................11
5
Occupation and income details for income protection only.................................................................................................................................................11
6Pastimes...................................................................................................................................................................................................................................................12
7Lifestyle.....................................................................................................................................................................................................................................................12
8
Doctors’ details......................................................................................................................................................................................................................................13
9
Main medical summary.......................................................................................................................................................................................................................13
10
Medical history.......................................................................................................................................................................................................................................14
10.1 Medical history – other............................................................................................................................................................................................................14
10.2 General health questions........................................................................................................................................................................................................14
10.3 Family history..............................................................................................................................................................................................................................15
10.4 Further medical questions...............................................................................................................................................................................................16-17
11
Access to medical reports.................................................................................................................................................................................................................18
12
General notes.........................................................................................................................................................................................................................................18
13a Declaration and consent for life assured 1..................................................................................................................................................................................19
13b Declaration and consent for life assured 2.................................................................................................................................................................................21
14
Accidental death benefit cover...........................................................................................................................................................................................23 & 25
15 Free cover benefit.....................................................................................................................................................................................................................23 & 25
16
Trustee details.......................................................................................................................................................................................................................................24
Direct Debit details......................................................................................................................................................................................................................................... 27
4 |
FAILURE TO DISCLOSE RELEVANT INFORMATION IN RESPONSE TO QUESTIONS ASKED MAY
RESULT IN NON-PAYMENT OF A CLAIM
1.About lives assured
also required for T-I
Please give the details here of any person on whose life an application for cover is being made.
Life assured 1
Life assured 2
Title: Mr, Mrs, Miss
or other title (eg Sir)
Marital status
First name
Last name
Second name
Date of birth
Sex
Smoker status
Occupation
Postcode
Address
Please note that one telephone
number is mandatory
Telephone number
Evening
Telephone number
Daytime
Telephone number
Mobile
Email address
2. About schemeholders
Please answer the questions below about the schemeholders only if different to the lives assured (above).
Applicant 1
Applicant 2
Title: Mr, Mrs, Miss
or other title (eg Sir)
First name
Last name
Second name
Date of birth
Postcode
Address
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FAILURE TO DISCLOSE RELEVANT INFORMATION IN RESPONSE TO QUESTIONS ASKED MAY RESULT IN NON-PAYMENT OF A CLAIM
Quote details
Please tick the relevant boxes below to specify the type of cover required.
Product
Life cover
Critical illness
cover
Critical illness
with life cover
Income
protection cover
Which life assured
(Please select one per product)
Life assured 1
Life assured 2
Joint life first event
Schemeholder
(Only complete if different from the lives assured. For income protection, the schemeholder must be the same as the life assured.
There can be a maximum of two schemeholders for each product)
Applicant 1
Applicant 2
Please state insurable interest
Term type and term of cover
(Please select one of the term types below and indicate the number of years the term is required in the appropriate box)
Mortgage protection
Number of years
(minimum of 5 years, maximum of 40 years)
Level
Number of years
Decreasing term assurance
Number of years
Family income benefit
(not available if applying for business cover)
Number of years
Renewable
Five years
Ten years
(if you select renewable premiums, your premiums may increase at each renewal without the need for further medical evidence based on the age of the
person covered and our premium rates at that time on each fifth or tenth year anniversary depending on the term you have selected)
Income protection (only)
(Please confirm your specific age in the appropriate box)
Term to retirement
Retirement age (50-70)Specific age
Fixed term
Number of years
Deferred period (months)
Limited benefit period
1
Yes
2
No
3
6
12
24
Premium basis
Guaranteed
Reviewable
Renewable
(only available with renewable term)
6 |
Quote details (continued)
Product
Life cover
Critical illness
cover
Critical illness
with life cover
Income
protection cover
Amount of benefit
Lump sum or Annual income
(only available with family income benefit) £
£
£
£
£
£
Monthly benefit
(only available with income protection cover)
£
Indexation
(not available with mortgage protection or decreasing term)
No
RPI
AWE
3%
5%
Reinstatement cover
Yes
No
Fracture cover
Life assured 1
Life assured 2
Life assured 1
Life assured 2
Life assured 1
Life assured 2
Monthly
Annual
Mortgage protection
Personal/family protection
Business protection
Is this product to be written in trust?
Total permanent disability
Premium waiver
Premium frequency
Reason for cover
(please select if ‘Yes’ and supply the relevant information as required in section 16)
Accidental death benefit (please see section 14)
Life assured 1 Life assured 2
Free cover benefit (please see section 15)
Is this application:
advised
non-advised
Are you submitting this application for tele-interviewing? (please select if ‘Yes’)
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Add more products - Quote details (please complete only if you wish to add more products to your application)
Please tick the relevant boxes below to specify the type of cover required.
Product
Life cover
Critical illness
cover
Critical illness
with life cover
Income
protection cover
Which life assured
(Please select one per product)
Life assured 1
Life assured 2
Joint life first event
Schemeholder
(Only complete if different from the lives assured. For income protection, the schemeholder must be the same as the life assured.
There can be a maximum of two schemeholders for each product)
Applicant 1
Applicant 2
Please state insurable interest
Term type and term of cover
(Please select one of the term types below and indicate the number of years the term is required in the appropriate box)
Mortgage protection
Number of years
Level
Number of years
Decreasing term assurance
Number of years
Family income benefit
(not available if applying for business cover)
Number of years
Renewable
Five years
Ten years
(if you select renewable premiums, your premiums may increase at each renewal without the need for further medical evidence based on the age of the
person covered and our premium rates at that time on each fifth or tenth year anniversary depending on the term you have selected)
Income protection (only)
(Please confirm your specific age in the appropriate box)
Term to retirement
Retirement age (50-70)Specific age
Fixed term
Number of years
Deferred period (months)
Limited benefit period
1
Yes
2
No
3
6
12
24
Premium basis
Guaranteed
Reviewable
Renewable
(only available with renewable term)
8 |
Quote details (continued)
Product
Life cover
Critical illness
cover
Critical illness
with life cover
Income
protection cover
Amount of benefit
Lump sum or Annual income
(only available with family income benefit) £
£
£
£
£
£
Monthly benefit
(only available with income protection cover)
£
Indexation
(not available with mortgage protection or decreasing term)
No
RPI
AWE
3%
5%
Reinstatement cover
Yes
No
Fracture cover
Life assured 1
Life assured 2
Life assured 1
Life assured 2
Life assured 1
Life assured 2
Monthly
Annual
Mortgage protection
Personal/family protection
Business protection
Is this product to be written in trust?
Total permanent disability
Premium waiver
Premium frequency
Reason for cover
(please select if ‘Yes’ and supply the relevant information as required in section 16)
Accidental death benefit (please see section 14)
Free cover benefit (please see section 15)
Is this application:
advised
non-advised
Are you submitting this application for tele-interviewing? (please select if ‘Yes’)
| 9
3. Existing cover
Please complete the following questions for both lives and all types of benefits. If you answer ‘Yes’ to any question below, please
give full details and dates where relevant.
Life assured 1
1. Is this application to replace an
existing Friends Life protection
policy (or policies)? In addition
to protection policies with a
Friends Life company, these
would also include protection
policies with Bupa Health
Assurance Limited, Friends
Provident or AXA Protection
Account policies.
Life assured 2
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
2. Please list all policy numbers
to be cancelled.
It remains the responsibility of
the schemeholder to ensure
that any cover no longer
required is cancelled, along with
the associated payment
arrangements.
3. Have you had, or have you
requested, a telephone
interview with Friends Life in
the last 12 months?
If “Yes”, please give a date of
telephone interview (mm/yyyy):
4. Have you ever had an
application for life, critical
illness or income protection
cover which has been turned
down or accepted on special
terms, eg an increased
premium or an exclusion?
If “Yes”, please give name of
company and date and details
of decision.
5. Does the amount of total
cover (life and critical illness)
that you already hold,
including any cover that is
currently proposed or
contemplated, exceed the
amount of £10 million? Types
of cover include, but are not
limited to, any personal cover,
mortgage cover (commercial
or personal), business cover
and death in service cover.
(not applicable if applying for
income protection cover)
If “Yes”, please give full details
of existing, pending and
contemplated cover. Any cover
under this application will be
subject to Friends Life Individual
Protection obtaining cover in
the reinsurance market.
10 |
4. Occupation
Life assured 1
Life assured 2
1. Please state your occupation.
Please also answer the questions below if you are applying for income protection cover, waiver of premium or total permanent
disability cover otherwise please move to section 5
2. Please state business miles
a year.
3. Please give details of any
manual work and percentage of
time spent on it.
4. Do you work at heights over
40 feet?
(If ‘Yes’, please state details
and percentage of time.)
Yes
No
Yes
No
5. Nature of business or industry
you work in:
5. Occupation and income details for income protection only
1. Please confirm your total earned
income or salary including
bonuses and commission in the
last 12 months.
2. Do you use power tools or
machinery?
If ‘Yes’, please state details
and percentage of time.
Life assured 1
Life assured 2
£
£
Yes
No
Yes
3. Average working hours a week:
No
hours
hours
4. A
re there any other hazardous aspects of your job or working
environment? eg working offshore
5. Are you self-employed?
If ‘Yes’, how long have you
been self-employed?
6. Please give details of your
gross annual income during the
last year (for self-employed,
income means personal
earnings as assessed for
income tax after deduction of
allowable expenses).
Yes
£
Yes
Dividends,
bonuses and
commission
No
Salary
£
Value
of P11D
benefits
£
Salary
£
7. What amount of gross annual income would continue past the
£
requested deferred period and
for how long?
£
8. Excluding state benefits and
this application, what amount
of monthly benefit eg income
protection, accident and
sickness, would continue past
the requested deferred period
and for how long?
£
£
Dividends,
bonuses and
commission
No
£
Value
of P11D
benefits
£
If you have selected more than one deferred period, please also complete questions 9 and 10
9. What amount of gross annual
income would continue past
and for how long?
£
£
10. Excluding state benefits and
this application, what amount
of monthly benefit eg income
protection, accident and
sickness, would continue past
and for how long?
£
£
| 11
6. Pastimes
1. D
o you, or do you intend to
take part in any hazardous
sports or activities such as
mountaineering, diving, private
flying, motor sport etc.?
Life assured 1
Yes
No
Life assured 2
Yes
No
If “Yes”, please advise what
exactly and complete the
appropriate questionnaire
7. Lifestyle
Life assured 1
1. Please state your height and
weight.
2. Have you used any form of tobacco or nicotine product in
the last 12 months?
Life assured 2
_________ft _________ins or _________ cms
_________ft _________ins or _________ cms
_________st _________lbs or _________ kgs
_________st _________lbs or _________ kgs
Yes
No
Yes
No
If “Yes”, please provide details.
• Number of cigarettes/cigars
a day
• Pipe smoker or other nicotine
usage.
Please note: random tests may be carried out to verify non-smoking.
3. How many units of alcohol do
you drink a week?
1 pint of beer = 3 units
1 glass of wine = 1.5 units
1 measure spirits = 1 unit
4. Have you ever been advised by your doctor or other medical practitioner to drink less
alcohol?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If “Yes”, please provide dates
and details.
5. Have you ever taken
recreational drugs, eg
cannabis, ecstasy, heroin, cocaine, or prescription drugs
not prescribed to you by a
doctor?
If “Yes”, please provide dates
and details.
6. During the last five years have
you lived or travelled abroad,
other than for normal holidays
of up to 30 days a year?
If “Yes”, please provide details
including the names of
countries and dates and
duration of visits.
Do you intend to do so in
the future?
12 |
8. Doctors’ details
Life assured 1
1. Name and address of your GP.
Name or Practice name
Please note we may not
necessarily contact your
Address
doctor. Even if we do, you must
still disclose all material facts.
2. If you have been registered with
this doctor for less than six
months, please provide details
of your previous doctor.
Life assured 2
Address
Postcode
Postcode
Telephone number
Telephone number
Address
Address
Postcode
Telephone number
Postcode
Telephone number
9. Main medical summary
If you answer ‘Yes’ to any question, please give full details, ie symptoms or diagnosis of condition, dates and duration, who was
consulted, details and results of any tests and whether or not a full recovery was made. Please note that for those conditions indicated
with an *, additional questionnaires will be required.
Please do not assume that we will contact your doctor and that your doctor will provide the information we need. It remains your
responsibility to complete this application form fully.
In accordance with the Association of British Insurers’ policy on genetics and insurance, you do not need to tell us about any genetic test
result you have had if this application for insurance, taken together with any other insurance policies you already have, totals up to £500,000
for life cover, £300,000 for critical illness cover and £30,000 a year for income protection.
Above £500,000 for life cover, £300,000 for critical illness and £30,000 a year for income protection, you may need to tell us about certain
genetic test results when applying for certain types of insurance. We will only be interested in genetic test results where the Government’s
Genetics and Insurance Committee has approved them for insurers to use. If you think this may apply to you, please ask us for details of the
current position. However, you must tell us if you either have a family history of, are experiencing symptoms of, or are having treatment for, a
medical condition including any genetically inherited condition.
1. Do you currently have or have you ever had any of the following?
If yes, please complete section 10.4 Further medical questions. Where questions have an *, please complete appropriate questionnaire.
Life assured 1
Life assured 2
a. Any form of cancer, leukaemia, Hodgkins disease, spinal tumour, lymphoma or melanoma?
Yes
No
Yes
No
b. Heart disorder including heart attack, angina, cardiomyopathy or heart murmur?
Yes
No
Yes
No
c. Stroke, brain haemorrhage, transient ischaemic attack (TIA), brain injury or brain tumour?
Yes
No
Yes
No
d. Multiple sclerosis, Parkinson’s disease, paralysis, Alzheimer’s disease, dementia or
cerebral palsy?
Yes
No
Yes
No
e. Numbness, loss of feeling, tingling, tremor or temporary loss of muscle power?
Yes
No
Yes
No
f. Blindness, blurred or disturbed vision not fully corrected by glasses or contact lenses,
eg optic neuritis or glaucoma?
Yes
No
Yes
No
g. Diabetes or sugar in the urine?*
Yes
No
Yes
No
h. Mental illness that has required hospital treatment or referral to a psychiatrist?*
Yes
No
Yes
No
| 13
10. Medical history
1) In the last five years, have you had any of the following?
a. A lump or growth of any kind; or any mole or freckle that has bled, become painful,
changed colour or increased in size?*
Life assured 1
Yes
No
Yes
No
b. Chest pain, irregular heart beat, raised blood pressure or raised cholesterol?
Yes
No
Yes
No
c. Asthma?*
Yes
No
Yes
No
d. Breathlessness, bronchitis, sarcoidosis or any lung disease other than asthma?*
Yes
No
Yes
No
e. Epilepsy, dizziness or blackouts?*
Yes
No
Yes
No
f. Deafness or any ear problem?*
Yes
No
Yes
No
g. Arthritis, or any muscle, bone or joint disorder (e.g. sciatica, back, neck, shoulder or knee
pain, RSI or gout)?*
Yes
No
Yes
No
h. Disorder of the digestive system, liver, stomach, pancreas or bowel including ulcers,
hepatitis, colitis or Crohn’s disease?*
Yes
No
Yes
No
i. Blood disorder or anaemia?
Yes
No
Yes
No
j. Thyroid disorder?*
Yes
No
Yes
No
k. Any kidney, bladder or other genito-urinary disorder, including blood or protein in the
urine, kidney cysts or multiple urinary tract infections?*
Yes
No
Yes
No
l. S
tress, anxiety, depression, insomnia, chronic fatigue or any psychiatric or eating
disorder?*
Yes
No
Yes
No
m.Any skin disorder or allergy?*
Yes
No
Yes
No
No
Yes
No
No
Yes
No
n. (Females only)
Abnormal cervical smear or mammogram, or had a biopsy of the breast, cervix or uterus?* Yes
o. (Males only)
Prostate enlargement or raised PSA (prostate specific antigen)?
Yes
Life assured 2
10.1 Medical History - other
1) In the last five years, other than for the medical conditions already mentioned, have you:
Life assured 1
Life assured 2
a. Had or have been advised to have any medical investigations, scans or blood tests?
Yes
No
Yes
No
b. Received any form of medical attention at a hospital as an in-patient or out-patient?
Yes
No
Yes
No
10.2 General health questions
1. Are
you currently experiencing any symptoms or disorder for which you have not
consulted a doctor?
2. Are you currently taking drugs, medicines or tablets or receiving any other treatment
for a condition not already mentioned?
3. A
re you currently awaiting a medical consultation or hospital appointment, or awaiting the
results of any tests?
4. Have you ever tested positive for HIV, hepatitis B or C or are you awaiting the results of a
test? (If the result was negative, the fact that you have had an HIV test will not affect your
application for insurance)
5. Within the last five years have you been exposed to the risk of HIV infection? (This can be
through unsafe sex, intravenous drug use or blood transfusions or surgery outside the EU)
6. Within the last five years have you tested positive or been treated for any disease which
was transmitted sexually?
Life assured 1
Life assured 2
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Please answer the following question if you are applying for income protection cover
not if you are applying for life cover or critical illness cover:
7. H
ave you had more than 15 days sick leave in the last two years?
14 |
10.3 Family history
Have any of your parents, brothers or sisters ever had any of the following medical conditions before they reached age 60?
If yes, please complete section 10.4 Further medical questions.
If you are unable to answer this section due to being adopted or similar circumstances, please indicate below and explain the reasons why you
are unable to answer in the space(s) below.
Life assured 1
Life assured 2
Alzheimer’s disease
Yes
No
Yes
No
Cancer
Yes
No
Yes
No
Diabetes
Yes
No
Yes
No
Haemochromatosis
Yes
No
Yes
No
Heart disease (including cardiomyopathy, heart attack or angina)
Yes
No
Yes
No
Huntington’s disease
Yes
No
Yes
No
Kidney failure or polycystic kidney disease
Yes
No
Yes
No
Motor neurone disease
Yes
No
Yes
No
Multiple sclerosis
Yes
No
Yes
No
Parkinson’s disease
Yes
No
Yes
No
Polyposis of the colon
Yes
No
Yes
No
Stroke
Yes
No
Yes
No
Any hereditary disorder?
Yes
No
Yes
No
Life assured 1
Life assured 2
| 15
10.4 Further medical questions
Life assured 1
Life assured 2
If you have answered ‘Yes’ to one or more of the questions in
sections 9 and 10, please complete the questions below for each
‘Yes’ answered.
If you have answered ‘Yes’ to one or more of the questions in sections
9 and 10, please complete the questions below for each ‘Yes’
answered.
1. The question number these details relate to:
Please provide full details in response to the relevant question
including the name of the illness, date of diagnosis, treatment given,
the results of any tests and whether a full recovery has been made.
16 |
10.4 Further medical questions (continued)
| 17
11. Access to medical reports
Please read this section carefully, as it sets out your rights under The Access to Medical
Reports Act 1988 and The Access to Medical Reports (NI) Order 1991.
In order to process your application and review any scheme issued, we may need to apply
for a medical report from any doctor who has attended you. To apply, we need you to give
your consent by signing the declaration below. You can choose from three courses of
action:
•you can give your consent without asking to see the doctor’s report before it is sent to
us. The report will then be sent directly to us by the doctor.
Should you give your consent to us obtaining a report without indicating that you wish to
see it, you can change your mind by contacting the doctor before the report is sent to us
in which case you will have the opportunity to see the report and ask the doctor to
change the report or add your comments before it is sent to us. Alternatively, you can
withhold your consent to its release.
•you can give your consent, but ask to see any report before it is sent to us, in which
case you have 21 days after we notify you that we have requested a report from the
doctor, to contact the doctor to make arrangements to see the report. If you fail to
contact the doctor within 21 days, he will be entitled to send the report directly to us. If
you do contact the doctor asking to see the report, you must give the doctor written
consent before he can release it to us. You may ask the doctor to change the report if
you think it is misleading. If the doctor refuses, you can insist on adding your own
comments to the report before it is sent to us. This does not prevent you from applying
to other companies for insurance.
•you can withhold your consent but, if you do, please bear in mind that we may be
unable to accept the application.
Whether or not you indicate your wish to see the report before it is sent, you have the
right to ask the doctor to let you see a copy, provided that you ask him within six months
of the report having been supplied to us. If you ask for a copy the doctor can charge you a
reasonable fee to cover the costs of supplying it.
The medical report your doctor fills in asks about the following:
• your current health
• any care, medication or treatment you are currently receiving
• the results of referrals or tests you are waiting for
• any time off work in the last three years
• your past health
•details of any relevant illness, trauma, or referrals for specialist advice or treatment,
hospital admissions, consultations with your GP or any other medical adviser, therapist
or counsellor, in particular whether you have a history of;
•malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative
(gradually worsening) diseases
•musculoskeletal disease or injury, for example, arthritis, rheumatism, back problems
or any other disorder of the joints or muscles;
•anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a
mental disorder where you lose contact with reality), stress or fatigue;
• suicidal thoughts or attempts at suicide; or
• conditions related to drug or alcohol misuse or smoking or chewing tobacco;
•details of any biopsies, blood tests, electrocardiograms (heart test), height, weight if
measured in the last two years, urinalyses (tests on urine), X-rays or other investigations
• any blood pressure readings in the last three years
•any history of disease among your parents or brothers or sisters that you have told your
doctor about.
We have asked your doctor not to reveal information about:
• negative tests for HIV, hepatitis B or C
•any sexually-transmitted diseases unless there could be long term effects on your
health; or
•predictive genetic test results unless there is a favourable test result which shows that
you have not inherited a condition your family suffers from.
The information you and your doctor provide about your health may result in us:
• refusing to provide insurance;
• increasing premiums above standard rates; or
• setting premiums at standard rates.
The doctor is entitled to withhold some or all of the report if (a) he feels that it may be
harmful to you or (b) it would indicate his intentions in respect of you or (c) it would reveal
the identity of another person without their consent (other than that provided by a health
professional in their professional capacity in relation to your care).
12. General notes
NOTE 1
Your membership will commence as soon as Friends Life Individual Protection has collected the first premium and has issued the registration
certificate.
NOTE 2
You are advised to keep a record of all information you supply to us in connection with this application including letters.
NOTE 3
Friends Life and you have a free choice about the law that can apply to a contract. Friends Life proposes to choose the law of England and
Wales, and, by entering into this contract you agree that the law of England and Wales applies and the terms are governed by the non-exclusive
jurisdiction of the English Courts.
NOTE 4
A COPY OF THE RULES APPLICABLE TO THE COVER FOR WHICH YOU HAVE APPLIED AND YOUR APPLICATION FORM ARE AVAILABLE
ON REQUEST. OTHERWISE THE RULES WILL BE SENT TO YOU WHEN YOUR APPLICATION FOR COVER IS ACCEPTED.
NOTE 5
It is our intention to provide a first class service to our members at all times. However, if you have any cause for dissatisfaction and have not
been able to resolve the problem and you wish to take your complaint further, please contact Customer Relations at the address or telephone
number on page 26. It is very rare that we can’t settle a complaint, but if this does happen, you may refer your complaint to the Financial
Ombudsman Service. You can write to them at The Financial Ombudsman Service, Exchange Tower, London E14 9SR, or call them on
0800 023 4567 or 0300 123 9123.
Please let us know if you want a full copy of our complaints procedure.
If something has gone wrong, we want to do everything we can to put it right. But none of these procedures affect your legal rights.
18 |
13a. Declaration and consent for life assured 1
Friends Life Individual Protection products are provided by Friends Life and Pensions Limited, part of the Friends Life group.
I consent to Friends Life Individual Protection seeking medical information from any insurance office to which an application has been made for
insurance on my life and I authorise the giving of this information. I understand that Friends Life Individual Protection may require sight of my
medical records to consider a claim.
I have been informed of my statutory rights under the Access to Medical Reports Act 1988 and The Access to Medical Reports (NI) Order 1991,
and, in connection with this current application, consent to Friends Life Individual Protection, obtaining medical information from any doctor
who, at any time, has attended me, or from any other relevant person concerning anything which affects my physical or mental health and I
agree that a copy of this consent shall have the validity of the original. I agree that Friends Life Individual Protection may request a medical
report following the issue of any scheme, using this consent, for a period of up to six months or any time after my death.
NB. If you do wish to see any report before it is sent to us, please delete the words in italics.
I do not wish to see any report before it is sent to Friends Life Individual Protection.
If you do not consent to Friends Life Individual Protection obtaining a medical report please put a cross in the following box.
You can withhold your consent but, if you do, please bear in mind that we may be unable to accept your application.
I acknowledge that Friends Life is not provided with this form and that it will consider any application and act only on the basis of the responses
to the questions in this form and any other information submitted to it in response to questions in the online application and in response to any
other questions asked of your client by you or by Friends Life Individual Protection with regard to the application.
Life assured 1 Signed
Date
7
7
Name (in BLOCK CAPITALS)
If known, please input the proposal number:
!
| 19
20 |
13b. Declaration and consent for life assured 2
Friends Life Individual Protection products are provided by Friends Life and Pensions Limited, part of the Friends Life group.
I consent to Friends Life Individual Protection seeking medical information from any insurance office to which an application has been made for
insurance on my life and I authorise the giving of this information. I understand that Friends Life Individual Protection may require sight of my
medical records to consider a claim.
I have been informed of my statutory rights under the Access to Medical Reports Act 1988 and The Access to Medical Reports (NI) Order 1991,
and, in connection with this current application, consent to Friends Life Individual Protection, obtaining medical information from any doctor
who, at any time, has attended me, or from any other relevant person concerning anything which affects my physical or mental health and I
agree that a copy of this consent shall have the validity of the original. I agree that Friends Life Individual Protection may request a medical
report following the issue of any scheme, using this consent, for a period of up to six months or any time after my death.
NB. If you do wish to see any report before it is sent to us, please delete the words in italics.
I do not wish to see any report before it is sent to Friends Life Individual Protection.
If you do not consent to Friends Life Individual Protection obtaining a medical report please put a cross in the following box.
You can withhold your consent but, if you do, please bear in mind that we may be unable to accept your application.
I acknowledge that Friends Life is not provided with this form and that it will consider any application and act only on the basis of the responses
to the questions in this form and any other information submitted to it in response to questions in the online application and in response to any
other questions asked of your client by you or by Friends Life Individual Protection with regard to the application.
Life assured 2 Signed
Date
7
7
Name (in BLOCK CAPITALS)
If known, please input the proposal number:
| 21
22 |
14. Accidental death benefit cover
IMPORTANT: THE FOLLOWING DETAILS ARE ALSO DUPLICATED ON PAGE 25 FOR YOU TO DETACH AND RETAIN FOR YOUR
REFERENCE
This cover is only available to applicants for level term assurance,
mortgage protection, decreasing term, renewable term or family
income benefit schemes providing life cover. You must have
selected the accidental death benefit for this cover to apply. It is
not available for any applicants for critical illness or income
protection schemes which will not provide life cover. The terms on
which accidental death benefit cover is provided are set out below.
Friends Life Individual Protection will pay the lower of:
(i) the sum assured requested in this application for schemes
providing life cover, as outlined above (“the proposed scheme(s)”);
or
(ii) £500,000 to the applicant(s) of the proposed scheme(s) on the
accidental death of any life to be assured under the proposed
scheme(s).
For the purposes of this cover accidental death will mean “death
arising solely and directly from bodily injury caused by external
violent, visible means totally independent of any physical or mental
illness or infirmity and occurring within 30 days of the accident”.
This cover will be provided from the date Friends Life Individual
Protection receives a completed signed application from the
applicant(s) for the proposed scheme(s) to cover the life to be
assured until the earliest of the following:
(i) Friends Life Individual Protection accepts the application for the
proposed scheme(s);
(ii) Friends Life Individual Protection notifies the applicant(s) that it
has rejected the application for the proposed scheme;
(iii) 90 days after the date on which Friends Life Individual
Protection received the application and this cover began.
Cover will not be provided in the following circumstances:
a) if the life to be assured (or either life to be assured) is aged 55 or
above;
b) if the claim is caused by suicide of the life to be assured (or
either life to be assured);
c) if the applicants have outstanding applications for the same, or
similar cover, with other Life offices;
d) if Friends Life Individual Protection have provided accidental
death benefit cover on the life to be assured (or the lives to be
assured) previously and no scheme was subsequently issued by
Friends Life Individual Protection.
These terms provide the entire terms on which Friends Life
Individual Protection will pay the sum assured under the accidental
death benefit cover. Friends Life and you have a free choice about
the law that can apply to a contract. Friends Life proposes to
choose the law of England and Wales, and, by entering into this
contract you agree that the law of England and Wales applies and
the terms are governed by the non-exclusive jurisdiction of the
English Courts.
15. Free cover benefit
IMPORTANT: THE FOLLOWING DETAILS ARE ALSO DUPLICATED ON PAGE 25 FOR YOU TO DETACH AND RETAIN FOR
YOUR REFERENCE
This cover is only available to applicants for scheme(s) accepted at
or below one and a half times the standard terms, which provide
life or critical illness cover to protect the mortgage for purchasing
or improving the main residence. The applicant(s) must have
received a mortgage offer letter from the lender. This cover will
commence when the applicant(s) has exchanged contracts
(missives in Scotland) or when work on improvements begins.
(ii) 90 days after the date on which Friends Life Individual
Protection offered acceptance terms;
You must have selected the Free cover benefit for this cover to
apply. It is not available for any applicants for income protection
schemes. The terms on which free cover benefit is provided are set
out below.
(v) in the event that Friends Life Individual Protection withdraws
the acceptance terms.
(i) the sum assured requested in this application for schemes as
outlined above (“the proposed scheme(s)”);
(ii) £500,000 to the applicant(s) of the proposed scheme(s) on the
death of any life to be assured under the proposed scheme(s); or
(iii) £350,000 to the applicant(s) of the proposed scheme(s) on the
diagnosis of a critical illness of any life to be assured under the
proposed scheme(s).
This cover will be provided from the date Friends Life Individual
Protection offers acceptance terms at or below one and a half
times the standard rates until the earliest of the following:
(i) the scheme(s) as outlined above (“the proposed scheme(s)) has
commenced;
(iii) on completion of the residence purchase (date of entry in
Scotland);
(iv) on the date when the mortgage is drawn down to pay for the
home improvements; or
a) if the life to be assured (or either life to be assured) is aged 55 or
above;
b) if the applicants have outstanding applications for the same, or
similar cover, with other Life offices;
c) if Friends Life Individual Protection has provided free cover
benefit on the life to be assured (or the lives to be assured)
previously and no scheme was subsequently issued by Friends Life
Individual Protection.
These terms provide the entire terms on which Friends Life
Individual Protection will pay the sum assured under the free cover
benefit. Friends Life and you have a free choice about the law that
can apply to a contract. Friends Life proposes to choose the law of
England and Wales, and, by entering into this contract you agree
that the law of England and Wales applies and the terms are
governed by the non-exclusive jurisdiction of the English Courts.
| 23
16. Trustee details
All trusts processed by the Friends Life online application system shall be trusts under English law. The Friends Life online application system
cannot be used for trusts under any law other than English law. If you wish to effect a trust written under any law other than English law, you will
not be able to do so via the Friends Life online application system and you must take your own specialist legal advice.
The Friends Life online trust process only allows for a trust request to be completed before the product is placed on risk. If the product is to be
assigned into trust after the product has been placed on risk, a paper trust deed is to be completed and sent to Customer Services.
Trustees
Is this product to be issued in trust?
Yes
No
If yes, the applicant will be automatically appointed as Trustee.
Do you want to add additional trustees?
Yes
No
The number of trustees should always be at least two (but cannot be more than 4 trustees at any one time - except for a joint life policy
where there can be a maximum of 6 trustees at any one time).
Please provide the names of each additional trustee:
Title
First Name
Last name
First Name
Last name
First Name
Last name
First Name
Last name
Address
Title
Address
Title
Address
Title
Address
Beneficiaries
When adding beneficiaries, please ensure these are different to the schemeholder(s).
Is this in equal shares for all beneficiaries?
Yes
No
If “No”, please complete the percentage share next to the name of each beneficiary.
Is this beneficiary to be a company / charity?
Yes
No
If “Yes”, please complete the company / charity in the box below.
Please provide the names of each beneficiary:
Title
First Name
Last name
Percentage share
or
company / charity name
Is the terminal illness benefit to be retained by the schemeholder?
Yes
No
24 |
!
Please detach and retain for your information.
Accidental death benefit cover
This cover is only available to applicants for level term assurance, mortgage protection, decreasing term, renewable term or family income
benefit schemes providing life cover. You must have selected the accidental death benefit for this cover to apply. It is not available for any
applicants for critical illness or income protection schemes which will not provide life cover. The terms on which accidental death benefit
cover is provided are set out below.
(i) the sum assured requested in this application for schemes providing life cover, as outlined above (“the proposed scheme(s)”); or
(ii) £500,000 to the applicant(s) of the proposed scheme(s) on the accidental death of any life to be assured under the proposed
scheme(s).
For the purposes of this cover accidental death will mean “death arising solely and directly from bodily injury caused by external violent,
visible means totally independent of any physical or mental illness or infirmity and occurring within 30 days of the accident”.
This cover will be provided from the date Friends Life Individual Protection receives a completed signed application from the applicant(s)
for the proposed scheme(s) to cover the life to be assured until the earliest of the following:
(i) Friends Life Individual Protection accepts the application for the proposed scheme(s);
(ii) Friends Life Individual Protection notifies the applicant(s) that it has rejected the application for the proposed scheme;
(iii) 90 days after the date on which Friends Life Individual Protection received the application and this cover began.
a) if the life to be assured (or either life to be assured) is aged 55 or above;
b) if the claim is caused by suicide of the life to be assured (or either life to be assured);
c) if the applicants have outstanding applications for the same, or similar cover, with other Life offices;
d) if Friends Life Individual Protection have provided accidental death benefit cover on the life to be assured (or the lives to be assured)
previously and no scheme was subsequently issued by Friends Life Individual Protection.
These terms provide the entire terms on which Friends Life Individual Protection will pay the sum assured under the accidental death
benefit cover. Friends Life and you have a free choice about the law that can apply to a contract. Friends Life proposes to choose the law
of England and Wales, and, by entering into this contract you agree that the law of England and Wales applies and the terms are governed
by the non-exclusive jurisdiction of the English Courts.
!
Please detach and retain for your information.
Free cover benefit
This cover is only available to applicants for scheme(s) accepted at or below one and a half times the standard terms, which provide life or
critical illness cover to protect the mortgage for purchasing or improving the main residence. The applicant(s) must have received a
mortgage offer letter from the lender. This cover will commence when the applicant(s) has exchanged contracts (missives in Scotland) or
when work on improvements begins.
You must have selected the Free cover benefit for this cover to apply. It is not available for any applicants for income protection schemes.
The terms on which free cover benefit is provided are set out below.
(i) the sum assured requested in this application for schemes as outlined above (“the proposed scheme(s)”);
(ii) £500,000 to the applicant(s) of the proposed scheme(s) on the death of any life to be assured under the proposed scheme(s); or
(iii) £350,000 to the applicant(s) of the proposed scheme(s) on the diagnosis of a critical illness of any life to be assured under the
proposed scheme(s).
This cover will be provided from the date Friends Life Individual Protection offers acceptance terms at or below one and a half times the
standard rates until the earliest of the following:
(i) the scheme(s) as outlined above (“the proposed scheme(s)”) has commenced;
(ii) 90 days after the date on which Friends Life Individual Protection offered acceptance terms;
(iii) on completion of the residence purchase (date of entry in Scotland);
(iv) on the date when the mortgage is drawn down to pay for the home improvements; or
(v) in the event that Friends Life Individual Protection withdraws the acceptance terms.
a) if the life to be assured (or either life to be assured) is aged 55 or above;
b) if the applicants have outstanding applications for the same, or similar cover, with other Life offices;
c) if Friends Life Individual Protection has provided free cover benefit on the life to be assured (or the lives to be assured) previously and
no scheme was subsequently issued by Friends Life Individual Protection.
These terms provide the entire terms on which Friends Life Individual Protection will pay the sum assured under the free cover benefit.
Friends Life and you have a free choice about the law that can apply to a contract. Friends Life proposes to choose the law of England and
Wales, and, by entering into this contract you agree that the law of England and Wales applies and the terms are governed by the
non-exclusive jurisdiction of the English Courts.
| 25
For more information, please contact us on:
0845 600 3122†
89044 UNI
FLIP/5441/Oct14
Friends Life Individual Protection, PO Box 569,
Friends Life Centre, Bristol, BS34 9FE
Or visit www.friendslife.co.uk/
individualprotection
†
Calls may be recorded and may be monitored
Friends Life and Pensions Limited
An incorporated company limited by shares and registered in England and Wales, number 475201.
Registered office: Pixham End, Dorking, Surrey RH4 1QA. Authorised by the Prudential Regulation
Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
Telephone 0845 600 3122 – calls may be recorded.
www.friendslife.co.uk
Friends Life is a registered trade mark of the Friends Life group.
26 |
Instruction to your Bank or Building Society
to pay by Direct Debit
Service user number
Friends Life Individual Protection
Please fill in the whole form using a ball point pen and send it to:
2
8
6
3
3
6
Registration numbers (if known)
Friends Life Individual Protection
PO Box 569
Friends Life Centre
Bristol
BS34 9FE
Name(s) of account holder(s)
Title: Mr, Mrs, Miss or other title (eg sir)
Bank account holder’s full postal address
Bank/Building Society Account
Number
Branch sort code
—
Postcode
—
Instruction to your Bank or Building Society
Name and full postal address of your bank or building society
To: The Manager
!
Bank/building society
Please pay Friends Life and Pensions Limited Direct Debits from the account detailed in this
Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this
Instruction may remain with Friends Life and Pensions Limited and, if so, details will be passed
electronically to my bank/building society.
Address
Signature(s)
Postcode
!
Date
Banks and Building Societies may not accept Direct Debit Instructions for some types of account
This Guarantee should be detached and retained by the payer.
The Direct Debit Guarantee
• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits.
• If there are any changes to the amount, date or frequency of your Direct Debit Friends Life and Pensions Limited will notify
you 10 working days in advance of your account being debited or as otherwise agreed. If you request Friends Life and
Pensions Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request.
• If an error is made in the payment of your Direct Debit by Friends Life and Pensions Limited or your bank or building
society you are entitled to a full and immediate refund of the amount paid from your bank or building society.
• If you receive a refund you are not entitled to, you must pay it back when Friends Life and Pensions Limited asks you to.
• You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be
required. Please also notify Friends Life and Pensions Limited.
| 27
89044 UNI
FLIP/5441/Oct14

Data capture form

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