Friends Life Protect+ Data capture for online personal cover, business cover and tele-interviewing

Transcription

1 Friends Life Protect+ Data capture for online personal cover, business cover and tele-interviewing FLIP/5441/Mar15 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 2

3 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. 3

4 The data capture form The form is made up of the following sections: 1 About lives assured About schemeholders... 5 Quote details Existing cover Occupation Occupation and income details for income protection only Pastimes Lifestyle Doctors details Main medical summary Medical history Medical history other General health questions Family history Further medical questions Access to medical reports General notes a Declaration and consent for life assured b Declaration and consent for life assured Accidental death benefit cover...23 & Free cover benefit...23 & Trustee details...24 Direct Debit details

5 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. 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 Telephone number Daytime Mobile address 2. About schemeholders also required for T-I 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 5

6 Quote details Please tick the relevant boxes below to specify the type of cover required. Which life assured (Please select one per product) Product Life cover Critical illness Critical illness Income cover with life cover protection cover 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 (minimum of 5 years, maximum of 40 years) Decreasing term assurance Number of years (minimum of 5 years, maximum of 40 years) Family income benefit (not available if applying for business cover) Number of years (minimum of 5 years, maximum of 40 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 indicate when you would like your policy to end in the appropriate box) Term to retirement (please indicate your specified retirement age, between ages 50 & 70) Or; Fixed Term (please indicate the required term for your policy. Minimum of 5 years, maximum of 52 years) Deferred period (months) Limited benefit period Yes No Premium basis Guaranteed Reviewable Renewable (only available with renewable term) 6

7 Quote details (continued) Product Life cover Critical illness Critical illness Income cover with life cover 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 Global Treatment (available once per applicant) Fracture cover Total permanent disability Premium waiver Premium frequency Monthly Annual Reason for cover Mortgage protection Personal/family protection Business protection Is this product to be written in trust? (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 ) 7

8 Quote details Please tick the relevant boxes below to specify the type of cover required. Which life assured (Please select one per product) Product Life cover Critical illness Critical illness Income cover with life cover protection cover 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 (minimum of 5 years, maximum of 40 years) Decreasing term assurance Number of years (minimum of 5 years, maximum of 40 years) Family income benefit (not available if applying for business cover) Number of years (minimum of 5 years, maximum of 40 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 indicate when you would like your policy to end in the appropriate box) Term to retirement (please indicate your specified retirement age, between ages 50 & 70) Or; Fixed Term (please indicate the required term for your policy. Minimum of 5 years, maximum of 52 years) Deferred period (months) Limited benefit period Yes No Premium basis Guaranteed Reviewable Renewable (only available with renewable term) 8

9 Quote details (continued) Product Life cover Critical illness Critical illness Income cover with life cover 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 Global Treatment (available once per applicant) Fracture cover Total permanent disability Premium waiver Premium frequency Monthly Annual Reason for cover Mortgage protection Personal/family protection Business protection Is this product to be written in trust? (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

10 3. Existing cover also required for T-I 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. 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. 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): Yes No Yes No 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. Yes No Yes No 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) Yes No Yes No 10 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.

11 4. Occupation also required for T-I 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 also required for T-I 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? Yes No Yes No If Yes, please state details and percentage of time. 3. Average working hours a week: hours 4. Are there any other hazardous aspects of your job or working environment? eg working offshore hours 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). 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? Yes No Yes No Dividends, Value Dividends, Value bonuses and of P11D bonuses and of P11D Salary commission benefits Salary commission benefits If you have selected more than one deferred period, please also complete questions 9 and What amount of gross annual income would continue past the requested deferred period 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 the requested deferred period and for how long? 11

12 6. Pastimes 1. Do you, or do you intend to take part in any hazardous sports or activities such as mountaineering, diving, private flying, motor sport etc.? Yes No Yes No If Yes, please advise what exactly and complete the appropriate questionnaire 7. Lifestyle 1. Please state your height and weight. 2. Have you used any form of tobacco or nicotine product in the last 12 months? 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 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? Yes No Yes No 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? Yes No Yes No Yes No Yes No 12

13 8. Doctors details also required for T-I 1. Name and address of your GP. Please note we may not necessarily contact your doctor. Even if we do, you must still disclose all material facts. Name or Practice name Address Telephone number Name or Practice name Address Postcode Postcode Telephone number 2. If you have been registered with this doctor for less than six months, please provide details of your previous doctor. Name or Practice name Address Name or Practice name Address Telephone number Postcode 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. 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

14 10. Medical history 1) In the last five years, have you had any of the following? If yes, please complete section 10.4 Further medical questions. Where questions have an *, please complete appropriate questionnaire. a. A lump or growth of any kind; or any mole or freckle that has bled, become painful, changed colour or increased in size?* 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. Stress, 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 n. (Females only) Abnormal cervical smear or mammogram, or had a biopsy of the breast, cervix or uterus?* Yes No Yes No o. (Males only) Prostate enlargement or raised PSA (prostate specific antigen)? Yes No Yes No 10.1 Medical History - other 1) In the last five years, other than for the medical conditions already mentioned, have you: If yes, please complete section 10.4 Further medical questions. Where questions have an *, please complete appropriate questionnaire. 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 If yes, please complete section 10.4 Further medical questions. Where questions have an *, please complete appropriate questionnaire. 1. Are you currently experiencing any symptoms or disorder for which you have not consulted a doctor? Yes No Yes No 2. Are you currently taking drugs, medicines or tablets or receiving any other treatment for a condition not already mentioned? Yes No Yes No 3. Are you currently awaiting a medical consultation or hospital appointment, or awaiting the results of any tests? Yes No Yes No 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) Yes No Yes No 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) Yes No Yes No 6. Within the last five years have you tested positive or been treated for any disease which was transmitted sexually? 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. Have you had more than 15 days sick leave in the last two years? Yes No Yes No 14

15 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. 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 15

16 10.4 Further medical questions 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: 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. 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. 2. The question number these details relate to: 2. 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. 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

17 10.4 Further medical questions (continued) 3. The question number these details relate to: 3. 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. 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. 17

18 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 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 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). 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. 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 or 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

19 13a. Declaration and consent for life assured 1 also required for T-I 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. We 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 the questions in the online application and in response to any other questions asked of you or by Friends Life Individual Protection with regard to the application. Signed 7 If known, please input the proposal number: Date 7 Name (in BLOCK CAPITALS)! 19

20 20

21 13b. Declaration and consent for life assured 2 also required for T-I 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. We 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 the questions in the online application and in response to any other questions asked of you or by Friends Life Individual Protection with regard to the application. Signed 7 If known, please input the proposal number: Date 7 Name (in BLOCK CAPITALS) 21

22 22

23 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. 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. Friends Life Individual Protection will pay the lower of: (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. 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 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

24 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 Address Title First Name Last name Address Title First Name Last name Address Title First Name Last name 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

25 ! FAILURE TO DISCLOSE RELEVANT INFORMATION IN RESPONSE TO QUESTIONS ASKED MAY RESULT IN NON-PAYMENT OF A CLAIM Accidental death benefit cover Please detach and retain for your information. 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.! 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. Friends Life Individual Protection will pay the lower of: (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. 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 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