University College Dublin (UCD) Income Protection Plan

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1 Your Guide to University College Dublin (UCD) Income Protection Plan Group policy number: 4707 June 2014

2 Contents Section 1 Object of the Plan 2 Section 2 Plan Benefits 2 Section 3 Cost of Plan Membership 2 Section 4 Joining the Plan and 3 Automatic Cover Conditions Section 5 General Conditions 3 Section 6 Further Information 4 Medi-phone Your Questions Answered 5 Foreword Under the terms of their Contract of Employment, permanent and pensionable employees of the University appointed since 1st September 2001 are automatically included in the Plan. Existing permanent and pensionable employees of the University are reminded that they may apply to join the Plan (see Section 4). The purpose of this booklet is to explain simply and concisely the benefits of the Plan. Members should however te that this booklet is only intended to give an outline of the Plan and does t create or confer any rights. The full provisions are contained in a policy issued by Irish Life Assurance plc. In the event of a dispute, the terms of the policy shall prevail. A copy of this policy document is available, on request, for inspection. The rates, terms and conditions of the Plan should be far superior to those that may otherwise be available to an individual effecting this vital cover on a personal basis. This Plan has been devised by Willis Risk Services (Ireland) Limited (trading as Willis) is regulated by the Central Bank of Ireland. Willis, Grand Mill Quay, Barrow Street, Dublin 4. Telephone (01) The benefits of the Plan are underwritten by Irish Life Assurance plc ("the Insurer") Irish Life Assurance plc is regulated by the Central Bank of Ireland. If you have any queries regarding the plan you should contact: Employee Benefits and Investments Division Willis Risk Services (Ireland) Ltd Grand Mill Quay Barrow Street Dublin 4 or Ph:

3 Section 1 - Object of the Plan The object of the Income Protection Plan is to provide an income to members in the event of long term disability and to supplement any early retirement pension that may be payable under the UCD Pension Scheme or State benefits (if any), subject to a maximum percentage of pre-disability income. The Plan also provides a source of income in the event of long-term partial disability provided that rmally such disability follows a period of receipt of benefit for total disability. Section 2 - Plan Benefits When will the benefit be paid? Benefit will become payable when you have had 26 weeks cumulative absence, (deferred period) due to sickness or accident, over a rolling four year period. This period dovetails with the sick pay arrangements of those members that have successfully completed their probationary period. What benefit will I receive if I am totally disabled? The income payable under the Plan will equate to 75% of salary at the time you cease work due to illness or injury and is inclusive of any retirement benefit, disability pension or sick pay from the University and, where applicable, basic Social Welfare Benefit at a single person s rate. Salary is defined as the salary you are in receipt of at the end of the deferred period. What benefit will I receive if I am partially disabled? A proportion of the income will be payable if, following a period of receipt of benefit for total disablement, and with the written permission of the Insurer, you resume your rmal occupation in a reduced capacity with reduced earnings, or you undertake some other suitable occupation at reduced earnings as a result of such disablement. The benefit payable would be 75% of your loss of earnings less any pension, State Disability Benefit or sick pay. The benefit payable in the event of partial disability must t exceed the benefit payable in the event of total disability. For how long will my income protection claim be payable? The benefit will be payable until the earliest of: 1. You recover. 2. You are deemed fit to return to work by Irish Life. 3. If while in receipt of benefit you re-engage in your rmal occupation or engage in some other occupation for profit or reward without the prior written consent of the Insurer. 4. Death. 5. Reaching your 65th Birthday. 6. Ceasing to be a permanent and pensionable employee of UCD for reasons other than early retirement on the grounds of ill-health. 7. You reside, without the Insurer s written approval, for a period of six months outside Ireland and the United Kingdom. Does the disability income increase? Yes. After you have been in receipt of income from the Plan for 12 consecutive months, the income under the Plan will increase annually by the lesser of 5% or the consumer price index. What is the definition of disablement? (a) Total disablement The inability of the member to carry out his/her rmal occupation because of sickness or accident and t following any other occupation. (b) Partial disablement The member being disabled as in (a) above, and either resuming their rmal occupation in a reduced capacity at reduced earnings or taking up an alternative occupation at reduced earnings. Section 3 - Cost of Plan Membership How much does the plan cost? The rate of contribution is subject to review every three years by the Insurer. Your contribution depends on whether you pay full PRSI (Class A1) or the reduced rate of PRSI (Class D1). The reason for this distinction is that Class A1 PRSI contributors should be entitled to Social Welfare disability/disablement benefits, which are taken into account in the benefit payable by the Insurer. Class D1 PRSI contributors do t rmally qualify for Social Welfare disability/disablement benefits, so there is offset from the Income Protection benefit payable. PRSI Class A1 D1 Rate 0.43% of salary 0.60% of salary This is inclusive of the 1% insurance levy, which was introduced by the Government on Life Assurance products in August Salary means the actual salary recognised for the calculation of retirement benefits under the UCD Pension Scheme and is inclusive of any pensionable allowances. 2

4 Reviewing the plan? The cost of the plan is reviewed every three years. If large numbers of people leave the plan or if there are a high number of people claiming, then Irish Life reserves the right to increase the cost of cover or cease cover altogether at the next review. Of course, the costs can also be reviewed downwards in the future. The term of this Group Policy is to the next review date. The premium rate will t change prior to the next review date.the next review of the plan will take place on 01/09/2014. Do I get tax relief on the Premiums paid? Yes. You can claim income tax relief on Income Protection premiums up to 10% of salary. The income tax relief is at marginal rate, and will be granted at source, i.e. as your premium is being deducted from your salary. It will t be necessary for you to personally claim this relief. Do I pay tax on the Benefit when it is paid? Yes. Benefits are treated as earned income for tax purposes and, as such, will be taxed under the PAYE/PRSI/USC system in the rmal way. Section 4 - Joining the Plan & Automatic Cover Conditions Am I automatically covered for benefits under the plan? Under the terms of your Contract of Employment, you will automatically be included in the Plan if you become a permanent and pensionable employee of the University on or after 1st September 2001, provided you do t decide to voluntarily opt out of the Plan. What is the position if I do t satisfy the automatic cover conditions? If you were eligible for membership prior to 1st September 2001 and did t join the Plan, or if you subsequently opted out of the Plan, you will be required to complete the Standard Application Form (page 7-10) if you wish to apply for membership w. This application form contains a number of medical questions. On receipt of your application form, the insurer will decide whether they require any additional medical evidence before making kwn their terms. Additional medical evidence can take the form of a tele-interview or a report from your own doctor and/or an independent medical examination. See page 10 for more information on the Medi-Phone process. Where you are required to complete an application form, cover will t commence until the insurer has accepted you as a member and issued written terms of acceptance. In certain cases the insurer may apply special terms or decline to offer cover. Where you are required to complete an application form, deductions from your salary will t commence until the insurer has issued written terms of membership. Where do I return completed application forms? All completed application forms should be returned to: UCD Compensation & Benefits Human Resources Roebuck Offices University College Dublin Belfield Dublin 4 Will evidence of health be required as my cover increases? Once you have been accepted for membership, either on satisfying the automatic cover conditions above or on subsequent submission of an application form, your cover will increase automatically as your salary increases without the need for further evidence of health. Cover is subject to the insurer s benefit limits as detailed in Section 5. Section 5 - General Conditions Will benefits be paid if I suffer injury or illness outside my place of employment? Yes. The plan provides cover on a 24 hour a day basis up to age 65 provided you are resident in the Republic of Ireland and United Kingdom. If you reside elsewhere, the written consent of the Insurers must be obtained. Are accidents and illnesses covered? Yes, except if disability arises from wilfully self-inflicted injury or illness, as per the Terms & Conditions of the Plan. Please bear in mind that in some cases individual members may be accepted into the Scheme subject to exclusions in respect of specific conditions. Once an exclusion is applied, sick leave due to the excluded condition cant be included in the calculation of deferred period. Are accidents while flying covered? Yes. If I am in receipt of benefit do I still pay premiums? No. When the deferred period is completed and a claim is admitted by the Insurer premiums are payable until the 3

5 claim ceases. Will I be covered if I return to work after benefit has ceased? Yes. Once you have been accepted by the Insurers for an amount of benefit they cant restrict the cover on account of subsequent medical history. Do I pay premiums if I am absent from work? If you are absent from work through injury or illness and in receipt of pay, premiums will be deducted. If your pay ceases so that deductions cant be made you will remain covered for a maximum period. This maximum period will be the period between the day pay ceases and the completion of the deferred period (ie. 26 weeks in a four year rolling period). Outstanding premiums will be recovered on return to work or if a claim is paid. What happens if I am on maternity leave? Your cover will continue for the duration of your paid maternity leave. If the duration of a career break and/or unpaid leave of absence exceeds 12 consecutive months, members will t rejoin the plan automatically on return to work. Such individuals will be classified as new entrants that do t satisfy the automatic cover conditions and, as such, will be required to complete an application form. Additional medical evidence may be required by the insurer. Please see Section 4 for further information. What happens if premiums are t deducted? If premiums are t paid, cover under the plan ceases. It is your personal responsibility to ensure premiums are deducted or otherwise paid. Failure to deduct premiums does t create a liability on UCD whose duty is to account for premiums actually deducted. What happens if I leave employment? Cover will automatically lapse on your ceasing to be an employee of University College Dublin. You may wish to consider seeking similar cover on a personal basis or through your new employer. What happens if I take unpaid parental or maternity leave? If you take unpaid parental or maternity leave, your cover will continue automatically without charge, subject to a maximum of 18 weeks in any one year. Premiums in respect of this period will be waived and deductions will recommence on return to work. If you take unpaid parental or maternity leave for longer than 18 weeks in any one year, your cover under the plan will cease until you return to work. What happens if I go on career break or unpaid leave of absence? You are t on cover whilst on career break. Members who take a career break for up to 12 months will rejoin the plan automatically on return to work and deductions will recommence immediately. In the rmal course of events, you are covered if you are absent due to illness for 26 consecutive weeks or for 26 weeks over a four year period. However, if you have been on a career break for any part of this 26 week period, it is t taken into account for the purpose of calculating sick leave entitlement or income protection benefits. Members who are on unpaid leave of absence, can maintain their cover for a period of up to 18 weeks unpaid leave in any 12 month period. Premiums in respect of this period will be waived. Provided that the duration of an unpaid leave of absence does t exceed 12 months, members will rejoin the plan automatically on return to work and deductions will recommence immediately. What is the maximum benefit payable under the plan? Your benefit cant exceed the lesser of: (1) 75% of your salary as defined less: (a) any amount of salary, earnings, profit, monetary reward or remuneration which you are in receipt of from your rmal occupation, or any other occupation or business that you may undertake subsequent to date of disablement; and (b) any ill-health retirement pension which is payable as calculated on the rmal basis as set down by your employer; and (c) an amount equal to the State Disability benefit payable to a single person, if entitled; and (d) any benefit you are receiving under the Social Welfare Act other than sickness, disability or treatment benefits payable to you under the Social Welfare Acts; and (e) any benefit you are entitled to under any other insurance against accident or sickness or other similar arrangement (where appropriate such an amount will be annualised), except in the case of once off lump sum Specified Illness cover policies; and 4

6 (f) any annualised amount awarded by an arbitration tribunal or court of law or agreed settlement sum or ex gratia payment attributable to loss of earnings arising out of any action relating to your disablement; Or (2) the maximum income protection benefit currently 150,000 per annum. What is the claims procedure? 60 days prior to the date your income is to reduce to half-pay, you should contact UCD Compensation & Benefits, Human Resources, Roebuck Offices, University College Dublin, Belfield, Dublin 4 who will provide the necessary forms. You should te the following: a) Admittance of a claim is subject to the Insurer being satisfied based on medical evidence received, that you are totally disabled from following your rmal occupation b) You may, as often as the Insurer decides, be asked to undergo a medical examination with an appropriate specialist, assessment by an occupational therapist or any other assessment or tests to include the taking and testing of blood, urine or other samples. Where you refuse to undergo, or fully comply with these requirements, then a claim will t be payable/paid. You may also be asked to undergo medical rehabilitation with a view to being rehabilitated back to your rmal occupation. Where you refuse to undergo, or fully participate in and commit to the medical rehabilitation, then a claim will t be payable/paid. This is a pre-arranged appointment time agree between the claimant and Irish Life. The insurer may also arrange for one of its Health Claims Advisors to call to you at your home address, either before any decision is made to admit the claim, or while the claim is in payment. This is a pre-arranged appointment time agreed between the claimant and Irish Life. While your claim is in payment, you may also be invited to attend a vocational consultant to explore other possible career options. The insurer will meet the costs of these referrals. c) It must be emphasised that information required by the insurer as outlined above must be dealt with fully and promptly. Undue delay, or failure to produce such information, may invalidate your claim. d) In the event of you failing to follow the advice of your own or any qualified medical practitioner all benefits payable or being paid under the policy shall cease. What happens if my claim is rejected? If the claim is rejected, there are a series of appeal procedures. These are as follows: 1. Direct Appeal This involves individual claimants making an appeal in which they should include any additional evidence to support their claim. Any such evidence is submitted for consideration by Irish Life and where relevant by Irish Life s Chief Medical Officer. If the evidence is accepted, the claim is paid. 2. Appeal to the Financial Services Ombudsman In the event that a direct appeal is t successful and the claimant is dissatisfied with the outcome, an appeal may be submitted to the Financial Services Ombudsman. This process involves obtaining from Irish Life a Final Response Letter and submitting this letter to the Financial Services Ombudsman with a request for a complaint form. This form must be completed and returned to the Financial Services Ombudsman with any relevant documentation. Once your complaint has been accepted as a matter of investigation your financial service provider will be asked to respond to the issue raised. If your complaint cant be accepted for investigation by the Ombudsman you will be informed as to the reason why. All the circumstances surrounding the complaint will be examined. Further information or supporting documentation may be requested from you. Every case is judged on its individual merits. In some cases it may be possible to reach a settlement to the satisfaction of both parties. If this is t possible, the Ombudsman will adjudicate upon the matter. Following adjudication, the complainant or the financial service provider concerned may appeal the Ombudsman s decision to the High Court. Section 6 - Further Information If you have any queries in relation to your membership of the Plan, please contact: Employee Benefits and Investments Division Willis Risk Services (Ireland) Ltd Grand Mill Quay Barrow Street Dublin 4 5

7 MEDI-PHONE: Your Questions Answered As part of the application process, Irish Life may ask that you complete a Medi- Phone interview, see below for more information on this process. What is Medi-phone? Medi-phone is an interview over the phone. We use it to gather medical or risk-related information when you apply for insurance cover. Risk-related information might include details of your current health, past medical history, family medical history, occupational risks and sports or hobbies. Calls take place at the time the applicant chooses on the application form, i.e. morning, afteron or evening, and will t be outside the hours of 9am and 9pm Monday to Saturday, excluding bank holidays and public holidays. How does Medi-phone work? All phone calls are made by qualified nurses who work for MorganAsh (a specialist company who are conducting the interviews on behalf of Irish Life). They will first ask you to confirm some personal information, as a security check and to ensure confidentiality and that you are comfortable to undertake the interview at that particular time. After this, they will ask you relevant questions to gather the health information we need. To make the process go smoothly please take some time to gather the following information to hand: 1. Details of any medication you are currently taking (name and dosage). 2. Details of any past or present medical conditions suffered. 3. Details of any tests or investigations, eg. blood pressure, cholesterol tests. You may like to phone your General Practitioner (GP) or whoever did these tests, to get the results. 4. You may be asked for your height and weight. If you do t kw your weight, please try to weigh yourself prior to the interview. 5. It is helpful to think about your recent medical history, for example in the past three years, did you visit the doctor or have you missed any time off work? If so, why and what medication did you receive? We will record the phone call which will be a permanent part of your application for cover. Calls should take approximately 15 to 30 minutes. Once we have gathered the relevant details as part of the Medi-phone call, a skilled Irish Life underwriter will assess the information and, in most cases, make a final decision on whether we can accept your application. Irish Life will then write to you to communicate this decision. In certain circumstances we may require some further medical evidence from your doctor and/or from yourself. You will be advised if this is necessary. 6

8 University College Dublin (UCD) Income Protection Plan arranged by Willis Standard Application Form Group Policy No Prior to completing this form please read each question. Please ensure that you fully understand all the questions and tes. Please use CAPITALS throughout. A copy of this completed proposal form is available on request. 1. PERSONAL DETAILS Title (Mr/Ms/etc) First Name Address Please use both the first name and surname in your employee records Surname d d m m y y y y Date of Birth / / Male Female Relationship Status Married Single Widow(er) Separated Divorced Civil Partner 2. EMPLOYMENT DETAILS Current Salary per annum Precise Occupation Work Address d d m m y y y y Date employment started / / Superannuation member? Social welfare class? A1 D1 Do you work more than 8 hrs per week on a permanent basis? 3. CONTACT DETAILS - MEDI PHONE From time to time, Irish Life may require more medical or risk-related information. If this is the case, you will be contacted by telephone by a nurse working for MorganAsh Ltd. (specialist company who carry out the phone calls on Irish Life s behalf) to obtain more information regarding your medical history. This will help Irish Life process your application more quickly. It is essential that you provide all requested information regarding your medical history. This telephone call will be recorded and will form part of your application for cover. For details of how the Medi-Phone call works, please see overleaf Medi-Phone: your questions answered. Contact Details - Please provide as many phone numbers as possible and your preferred contact time. Telephone: Home: Mobile: Work: Address: Preferred contact time: Morning Afteron Evening Normally, you will be contacted within a couple of days or so of Willis submitting your application form to Irish Life. If, when you are called, it is t a convenient time, then just ask to re-arrange to a more convenient time. If you have t been contacted within 3 days, or you have been away or out of touch you may like to phone MorganAsh on Free-phone The interview can be undertaken up to 9.00pm at night and during the day on Saturdays. If you have call barring on your phone, please arrange to allow MorganAsh to phone you, or you may like to call them on the above number. It is important that you are in a confidential situation and have the time to spare to undertake the interview. MorganAsh will t undertake the interview if you are driving. 7

9 4. FURTHER DETAILS Please give the name and address of your General Practitioner (GP). Name & Address of GP: If you have changed doctor in the last year, please give the name and address of your previous doctor. Name & Address of previous GP: 5. MEDICAL AND OTHER INFORMATION Please read the questions below and ensure that you fully understand each question before answering it. Warning - Telling Irish Life about material facts Please remember that you must tell us everything relevant when answering all of the questions on the application form and/or during the Medi-Phone call. If you do t, or if any of the answers to these questions are t true & complete, we could treat the plan as void. If failure to reveal all facts occurs there will be cover under the plan and we will t refund the payments. In these circumstances we will t pay a claim. Failure to disclose all facts may result in difficulty for you in trying to obtain cover elsewhere. A material fact (relevant information) is one that an insurer would regard as likely to influence the assessment and acceptance of the application for insurance. If you are t sure whether something is relevant, you should tell us anyway. Irish Life will rely on what you tell them and you must t assume that Irish Life will automatically clarify or confirm any information you provide. You do t need to tell Irish Life about any genetic test (that is any analysis of chromosomes, DNA or RNA to detect genetic abrmalities in individuals) which you may have had. You must however, tell Irish Life if you are having treatment for or are experiencing symptoms of a genetic condition. If your health changes between the date you apply for cover and the date your application is accepted, you must let us kw immediately as failure to do so may result in a claim being refused. 1. In the last 3 years, have you had time off work due to illness or injury for more than 10 consecutive working days (colds or influenza may be igred)? 2. Have you ever had back pain, sciatica, neck, shoulder, knee or any other muscular or joint pains? 3. Have you ever had stress, anxiety, depression or any other mental health problems? 4. In the last year have you been prescribed or advised to take any medication or treatment including tablets, creams, inhalers, drops or sprays (Oral contraceptive pill or treatment for colds, influenza & respiratory tract infections may be igred)? 5. In the last 5 years, have you had or been advised to have any tests or investigations or are you awaiting the results of any tests or investigations? 6. In the last 5 years, have you attended a specialist, hospital or clinic or have you been admitted to hospital (in-patient periods in respect of rmal pregnancy and delivery, appendectomy or tonsillectomy need t be disclosed)? 7. Are you currently unwell or do you have any medical condition or physical impairment that is t already disclosed above? 8. Have you ever been declined, postponed or accepted on special terms by Irish Life or any other insurer for life, serious (critical) illness or income protection? Question Nature of illness Duration & dates off work Name & address of Doctor consulted 8

10 6. DECLARATION - YOU MUST READ CAREFULLY BEFORE SIGNING Warning: Please read the declaration below carefully and ensure that you fully understand it before signing it. If you cant complete this declaration, please contact your financial advisor for further information. I wish to join the income protection plan for UCD employees. I confirm that I am an employee of UCD. I understand that it is a condition of membership that I accept that UCD may amend the terms of the UCD plan or terminate the UCD plan altogether and that decisions of UCD in such matters are binding on all members. I confirm that I have received, read and understand the key features of the scheme booklet. I declare that I am actively at work today, or capable of being actively at work today*. I understand and agree that my contract with Irish Life will be based on this application form including all declarations and consents, any supplementary questions answered, any statements made to Irish Life s underwriting team or in response to any phone calls received by Medi-Phone call, any information I give to a medical examiner acting for Irish Life Assurance plc and all terms and conditions furnished to me by Irish Life and your financial advisor. I have read and understand the important information concerning my obligation to tell Irish Life Assurance plc about all material facts (relevant information) in connection with the application and all my answers to the questions asked are in every respect true and complete. I understand that if I do t tell Irish Life Assurance plc all material facts (relevant information), this contract could be void. If this happens, there will be cover under the contract and premiums will be refunded. In these circumstances, Irish Life will t pay a claim. I also understand that I may encounter difficulty in obtaining cover elsewhere. I consent to Irish Life obtaining information from or sharing information with: any doctor who at any time has attended me concerning anything which affects my physical or mental health any health professional for the purpose of processing my application any insurance company where I may have applied or may make a claim I authorise Irish Life to access and receive this information. I agree that this authority will stay in force after my death. I understand that I must tell Irish Life in writing about any changes in my health or circumstances between the date I applied for cover and the date my application is accepted. I understand that this contract will t start until Irish life has accepted me for cover. PLEASE TAKE THE TIME TO REVIEW THE ABOVE STATEMENTS AND YOUR ANSWERS TO THE QUESTIONS. *Actively at work means that you: are working your rmal contracted number of hours have t received medical advice to refrain from work; and are mentally and physically capable of fully performing the rmal duties associated with your occupation x d d m m y y y y Applicant s Signature Date / / 7. DATA PROTECTION DECLARATION Data Protection Notices 1. The information that you provide to Irish Life will be held on a computer database and/or any other way and will be used to administer this plan and any other products and services supplied to you and any future agreements, contracts or arrangements you may have with Irish Life. 2. You have the right of access to your personal data held by Irish Life by sending a written request and on payment of a small fee. 3. You also have the right to require Irish Life to correct any inaccuracies in the personal data that it holds about you. 4. You also have the right to question the purpose for which your data is held. Data Protection Consents I declare that I consent to the A. processing and holding (on computer or otherwise) of all information disclosed by me, or on my behalf, in relation to the plan by Irish Life, its servants and agents (together with such other information supplied or obtained by Irish Life) including sensitive personal data (being medical records and/or financial details) and holding or processing of same for underwriting, administrative, customer care and service purposes, and B. disclosing of my data (personal and sensitive) to persons necessary in connection with the above purposes, to the regulatory authorities or as is required by law, to Irish Life Assurance plc and to other companies in the Irish Life Group or the Great-West Lifeco Group, to reinsurers and health professionals. This may involve the transfer of personal data, including sensitive personal data, to countries outside the European Ecomic Area. x d d m m y y y y Applicant s Signature Date / / 8. SALARY DEDUCTION MANDATE PLEASE SIGN Employer s Name Employer s Address Staff Number d d m m y y y y Date of Birth Date / / Please deduct from my salary the appropriate contribution under the UCD Income Protection Plan. I recognise that these deductions, being made solely as a measure of convenience to me, may be terminated at any time. I also recognise that the ultimate responsibility for ensuring that the deductions have, in fact, been made from my salary rests with myself, and that, beyond making remittances direct to Irish Life Assurance plc in accordance with the arrangements approved, the employer accepts responsibility of any kind in that matter. x d d m m y y y y Applicant s Signature Date / / 9

11 9. MEDI-PHONE YOUR QUESTIONS ANSWERED What is Medi-Phone? Medi-Phone is an interview over the phone. We use it to gather medical or risk-related information when you apply for Income Protection cover. Riskrelated information might include details of your current health, past medical history, family medical history, occupational risks and sports or hobbies. How does Medi-Phone work? All phone calls are made by qualified nurses who work for MorganAsh (a specialist company who are conducting the interviews on behalf of Irish Life). They will first ask you to confirm some personal information, as a security check and to ensure confidentiality and that you are comfortable to undertake the interview at that particular time. After this, they will ask you relevant questions to gather the health information we need. 1. Details of any medication you are currently taking (name and dosage). 2. Details of any past or present medical conditions suffered. 3. Details of any tests or investigations, e.g. blood pressure, cholesterol tests. You may like to phone your G.P. or whoever did these tests, to get the results. 4. You may be asked for your height and weight. If you do t kw your weight, please try to weigh yourself prior to the interview. 5. It is helpful to think about your recent medical history, for example in the past three years, did you visit the doctor or have you missed any time off work? If so, why and what medication did you receive? The call will be recorded and will be a permanent part of your application for cover. Calls should take approximately 15 to 30 minutes. Once we have gathered the relevant details as part of the Medi-Phone call, a skilled Irish Life underwriter will assess the information and, in most cases, make a final decision on whether we can accept your application. Your financial advisor will then write to you to communicate this decision. In certain circumstances we may require some further medical evidence from your doctor and/or from yourself. You will be advised if this is necessary. A copy of the interview will be sent to you for your records. If you need to change anything, or would like to add anything to the report, you can make the amendment, sign it and return it to Irish Life in the Freepost envelope provided with the report. What are the advantages of Medi-Phone over getting the information by paper? 1. We tailor each interview to you and your personal circumstances making the process easier and quicker than completing a standard application form. 2. It may be more convenient for you. 3. We can get better quality information on your health history. What happens if I do t want to discuss my medical details over the phone? This is t a problem. Following a Medi-Phone call, if you are t happy providing your medical details over the phone, we will post you the relevant forms for your completion. You can then post these forms back to Willis. If you have any questions in relation to this please contact Willis on ELIGIBILITY To be eligible to apply for membership of the UCD Income Protection Plan with this form you must be: An employee of UCD Under age 60 and Working for 8 hours or more per week employed on a permanent basis 11. CONFIRMATION OF PLAN MEMBERSHIP Your cover will commence from the date Irish Life accepts your application. You will receive a formal acceptance letter confirming that you have been included as a member of the UCD Plan. Irish Life will assess the potential risk of insuring you before membership of the Plan can be confirmed. This may involve attending for a medical examination. In a small percentage of cases membership of the UCD Plan may be refused. In such cases applicants will receive a letter confirming that they have t been accepted into the Plan. In other cases membership may be offered subject to the condition that certain medical conditions are excluded from cover or subject to the payment of an additional contribution. In these circumstances applicants may seek additional clarification from their own doctor who can contact Irish Life to request reasons for their decision. When completed, please sign and date this form and return to: UCD Compensation & Benefits, Human Resources, University College Dublin, Belfield, Dublin 4. Willis Risk Services (Ireland) Limited (trading as Willis) is regulated by the Central Bank of Ireland. Irish Life Assurance plc is regulated by the Central Bank of Ireland. In the interest of customer service we may record and monitor calls. Irish Life Assurance plc, Registered in Ireland number , Vat number 9F55923G. Willis Risk Services (Ireland) Limited (trading as Willis) is regulated by the Central Bank of Ireland. Irish Life Assurance plc is regulated by the Central Bank of Ireland. In the interest of customer service we may record and monitor calls. Irish Life Assurance plc, Registered in Ireland number , Vat number 9F55923G. Lower Abbey Street, Dublin 1, Ireland T: F:

12 Contact us phone: fax: website: write to: CB Voluntary Risk, 4th Floor, Irish Life Assurance plc, Lower Abbey Street, Dublin cb (rev 6-14) Irish Life Assurance plc is regulated by the Central Bank of Ireland. Willis Risk Services (Ireland) Limited (trading as Willis) is regulated by the Central Bank of Ireland. In the interest of customer service we may record and monitor calls. Irish Life Assurance plc, Registered in Ireland number , Vat number 9F55923G.

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