CONTINUATION OPTION FORM EXECUTIVE INCOME PROTECTION & LIFE COVER FOR EXISTING FRIENDS FIRST POLICYHOLDERS

Size: px
Start display at page:

Download "CONTINUATION OPTION FORM EXECUTIVE INCOME PROTECTION & LIFE COVER FOR EXISTING FRIENDS FIRST POLICYHOLDERS"

Transcription

1 CONTINUATION OPTION FORM EXECUTIVE INCOME PROTECTION & LIFE COVER FOR EXISTING FRIENDS FIRST POLICYHOLDERS Agency Nuber: Agency Nae: OFFICE USE: Contract Type: Policy/Contract No.: Client No. (Eployer): Client No. (Eployee): Please coplete this application in BLOCK CAPITALS and tick any relevant boxes. Once you have subitted this application you ay ask for a copy to be sent to you. SECTION 1 PERSONAL DETAILS EMPLOYER S DETAILS Nae of eployer: Business Address: Registered Address: (if different fro business address) EMPLOYEE S DETAILS Mr. Mrs. Ms. First Nae: Eployer Tax Reference No.: Date of birth: Surnae: Address: Is the eployee a 5% director? Yes: No: Is the eployee a 20% director? Yes: No: Date of entry into service: Reuneration (see notes below) Have you soked any cigarettes, cigars, pipes or tobacco in the last 12 onths? If yes, how any per day? Yes No (a) Basic Salary (per annu) (b) Fluctuating eoluents (per annu) (averaged over the last 3 years) Notes: (For Section 1.) (a) Directors fees can be treated as reuneration only if: (i) the director is beneficially entitled to the fees and any other reuneration and is not under an obligation to account for the to another copany or eployer; and (ii) the fees and other reuneration are not being treated for tax purposes as a receipt of a profession in which the director is engaged. If these conditions are not applicable the aount of director s fees should be oitted. If included, directors fees ay rank as either basic salary or fluctuating eoluents, according to the basis on which they are voted. (b) Final reuneration for a 20% director is based on the average of total eoluents for any three or ore consecutive years ending not earlier than 10 years before the noral retireent date. If this application is in respect of such a director who is within 3 years of the selected retireent age, the basic salary shown above should be averaged over at least 3 years (or such shorter tie as he/she has been in the service of the Eployer). (c) A 20% director is one who, either alone or together with his/her spouse and inor children, is or becoes or at any tie within 3 years of the specified noral retireent date, or earlier retireent, or leaving service, the beneficial owner of shares which, when added to any shares held by the trustees of any settleent to which the director of his/her spouse had transferred assets, carry ore than 20% of the voting rights in the copany providing the benefits or in a copany which controls that copany. AF290, Mar. 15

2 SECTION 2 PRODUCT DETAILS (NOTE: NEW BENEFITS MUST EQUAL THOSE UNDER THE EXISTING POLICY) INCOME PROTECTION Monthly benefit: (Maxiu overall benefit is x14,583 per onth) Pension Contribution Cover: (Maxiun x3,334 per onth) Age at which benefit will end: Deferred period: onths Preiu type: Guaranteed: or Reviewable: Indexation: Yes: No: Benefit during clai: Level: 3%: (benefit increases by 3% per annu, and preiu increases by 3.5% per annu with this option) (this option does not affect the preiu, but the benefit paid during clai only will increase by 3% per annu) EXECUTIVE PENSION TERM ASSURANCE Su Assured: Ceasing Age: Start date: Level: Increasing: INCOME PROTECTION & EXECUTIVE PENSION TERM ASSURANCE Frequency of preiu: Monthly: Quarterly: Half Yearly: Annually: Annual preius ay be paid by cheque; all other frequency preius ust be paid by direct debit. Policy start date: Preferred preiu collection day: SECTION 3 DETAILS OF YOUR OCCUPATION What is your occupation? Type of business you work in: Gross Annual Salary: Are you self eployed or a share-holding director? Yes: No: If Yes, for how long? Years: Months: Nuber of eployees working for you (including sub-contractors) if applicable? If you were unable to drive, could you still carry out your current occupation? Yes: No: Do you work in any of the following areas? - Ared Forces - Aviation - Fishing - Mining, Quarrying or Tunnelling Yes: No: - Motorcycle Couriering - Oil & Gas Exploration or Nuclear Energy - Professional Sports or Diving - At exposed heights of over 40 feet / 12 etres? - With high voltage, explosives, hazardous aterials, furnaces or tarac / asphalt If yes, please provide details of the nature of your work, including your job title. Additional Inforation

3 SECTION 4 DECLARATIONS PLEASE READ CAREFULLY THE FOLLOWING DECLARATION, AS IT WILL FORM PART OF THE CONTRACT a) The Eployer A. requests Friends First Life Assurance Copany Liited (Friends First) to issue a policy or policies subject to the conditions prescribed by Friends First which are to be set out therein for the provision of benefits corresponding to those provided in the above entioned plan for ebers thereof and, B. agrees to pay or procure payent of all preius as set out in the policy or policies, and C. declares that to the best of our knowledge and belief the stateents ade in the above application are true and coplete and that this declaration and the inforation to be given as to the relevant particulars of the eber involved and any subsequent declarations shall be the basis of the policy or policies to be effected with Friends First and that any stateent ade to Friends First or a Medical Officer of Friends First by a eber, or an agent acting on their behalf, in respect of who a benefit is to be assured shall as regards such benefit, also be the basis of the policy or policies and, D. declares that, to the best of our knowledge and belief, the participant s details provided herein are correct. Signature of eployer Eployer: Please sign and date. Position in Copany Print Nae b) The Eployee I confir that: I a/was a eber of was. Reason for leaving service Group Life/Peranent Health Schee, and y date of leaving service I did not leave service of y eployent due to ill health, retireent, or any other excluded circustance as set out in the policy conditions fro y Group Schee. I userstand that if any part of the Benefit in respect of the Group Schee of which I was a eber was the subject of an adverse underwriting decision, siilar ters will be iposed on the entire su insured of this new policy. I subit this application, along with any subsequent inforation provided in relation to this application, verbally or otherwise, by e or an agent acting on y behalf, with a view to entering into a contract for the benefits set out herein. I understand that the policy will coence on the coenceent date indicated on the policy or on such other date as notified by Friends First. I understand that ters and conditions, as provided to e, will apply. I have read over the replies to all questions in this application and declare that to the best of y knowledge and belief, all inforation given is true and includes all aterial facts and I understand that failure to disclose all relevant facts, including full disclosure of y edical details and history, ay delay or prevent the issue of y policy and/or ay invalidate future clais. If you are in any doubt as to whether a fact is a aterial fact you should disclose it. I consent to Friends First, verbally or otherwise, seeking and receiving additional inforation fro e or y agents where this inforation has not been provided on the application or where further inforation including edical inforation, is required in order to process the application and such inforation will be deeed to be incorporated into this application. I undertake to infor Friends First of any change in y country of residence during the life of the policy. I understand that in the interest of custoer service and to ensure the accuracy of records, telephone conversations between Friends First and e ay be recorded. I understand that a written instruction ust be provided to Friends First requesting the cancellation or alteration of this policy and that Friends First will not be in a position to refund any preius paid prior to receiving this request. It is y responsibility to notify Friends First of any change in y circustances. Eployee: Please sign and date. Signature of life to be assured:

4 SECTION 4 DECLARATIONS (CONTINUED) c) Data Protection Friends First Life Assurance Copany Liited ( Friends First ) or its authorised agents ay hold, use, disclose and process any inforation provided by e, which shall include the inforation held within this application and any subsequent inforation, provided verbally or otherwise, during the course of our relationship, in order to: 1. process, anage, and adinister y policy 2. counicate with e by post, telephone or e-ail 3. coply with legal and regulatory requireents 4. disclose data to any policyholder, life assured, beneficiary, trustee, assignee, successors, copany within the Achea/ Friends First group or to any agent acting on your behalf, or to other disclosees as notified to the Data Protection Coissioner s Office and aintained on the Public Register available fro that office. I a aware that I have the right of access to y personal data and the right to rectify y data if it is inaccurate or has been processed unfairly. I consent to Friends First collecting and processing sensitive data relating to y ental and physical health. I consent to Friends First seeking edical inforation fro any doctor or other edical professional who has at any tie attended e concerning anything which affects y physical or ental health. I agree that this authority shall reain in force after y death as well as prior thereto. I further understand that in the event of e being edically exained the answers given by e to the edical exainer acting on behalf of Friends First shall be deeed to be incorporated into this application. Please note that failure to consent to the above will prevent Friends First fro processing your application further, furtherore, failure to answer any question contained herein ay result in Friends First refusing to accept your application or denying a clai. Your personal data ay also be used to send you details about other siilar services available fro Friends First. If you do not wish to avail of this service, please tick this box. Life assured: Please sign and date. Signature of life to be assured: Additional Inforation

5 SECTION 5 SEPA DIRECT DEBIT MANDATE Unique Mandate Reference (UMR): Originator s ID nuber: I E 6 S D D By signing this andate for, you authorise (A) Friends First Life Assurance Copany Liited to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions fro Friends First Life Assurance Copany Liited. As part of your rights, you are entitled to a refund fro your bank under the ters and conditions of your agreeent with your bank. A refund ust be claied within 8 weeks starting fro the date on which your account was debited. Your rights are explained in a stateent that you can obtain fro your bank. Please coplete all the fields arked *. *Nae of Account Holder *Address of Account Holder *City/postcode *Country *IBAN Account nuber: *BIC Code: Type of payent: Recurrent payent: By signing this andate for, you authorise Friends First to provide at least 4 days advance notice before the first direct debit is collected fro your account. *Nae of account to be debited: Joint Account 1st Account Holder 2nd Account Holder *Signatures for Joint Accounts requiring two signatures: 1st Signature 2nd Signature *Nae of account to be debited: Single Account Account Holder: * I confir that only y signature is required on this account Signature: * Policyholder s nae, if different fro nae of account to be debited: Please return this andate to Friends First Life Assurance Copany Liited and not your bank: Creditors Nae: Friends First Life Assurance Copany Liited. Creditors Address: Friends First Life Assurance Copany Liited Preiu Collection Departent, Cherrywood Business Park, Loughlinstown, Dublin 18.

6 Additional Inforation

7 LETTER OF EXCHANGE (NOTE: THIS IS FOR EXECUTIVE TERM ASSURANCE ONLY). To: Friends First ( the Eployer ) has decided to establish with effect fro ( the Coencing Date ) a Retireent Benefits Plan to be known as the Retireent & Death Benefits Plan ( The Plan ) for ( Mebers Nae ) to provide you with retireent benefits. The Plan is governed by this Letter and Rules ( The Rules ); you will receive a copy. The benefits under the Plan will be secured by a policy or policies issued by Friends First Life Assurance Copany Liited ( Friends First ) in accordance with the declarations ade in the application for(s) to which this Letter is attached and any additional declarations ade to Friends First for the purposes of this Plan. The policy or policies issued by Friends First will be held by the Eployer (if corporate body) or by and and (if non-corporate body) as Trustee(s) of the Plan for payent of the benefits in accordance with the Rules. The Preius payable towards the provision of the benefits under the Plan will be contributions ade by you and/or the Eployer in accordance with the declaration(s), subject always to the Rules. The Eployer now establishes the Plan under irrevocable trusts to be adinistered in accordance with the Rules, being a retireent benefit plan capable of being approved by the Revenue Coissioners as an exept approved plan under Part 30 Chapter 1 of the Taxes Consolidation Act 199 providing you with relevant benefits as defined in the Section 0 of the Taxes Consolidation Act 199. Please acknowledge acceptance of this Letter and of the Rules by signing below and returning this Letter to the Eployer. Yours sincerely, Signature for the Eployer Nae In block capitals Position Status I agree to the Ters and Conditions of this Letter and attached Rules. Signature of eber Nae In block capitals Date We the Trustees of the Plan appointed in this Letter of Exchange hereby consent to act as Trustees. Signature of trustee Signature of trustee Signature of trustee Date Date Date

8 Friends First Life Assurance Copany Ltd Friends First House Cherrywood Business Park Loughlinstown Dublin 18 Friends First Life Assurance Copany Liited is regulated by the Central Bank of Ireland. In the interest of custoer service and to ensure the accuracy of our records calls will be recorded and onitored.

INCOME PROTECTION InsURANCE INITIAL CLAIM form

INCOME PROTECTION InsURANCE INITIAL CLAIM form INCOME PROTECTION InsURANCE INITIAL CLAIM for Sales Person: Agent/Agency No.: We need the inforation in this for, together with any other edical or financial evidence which ay be requested, so that we

More information

LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME APPLICATION FORM

LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME APPLICATION FORM LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME APPLICATION FORM SECTION 1 PERSONAL DETAILS Mr. Mrs. Ms. Date of birth: First Name: Surname: Address: Contact Numbers: Home Work Mobile Email SECTION 2 MEMBERSHIP

More information

CONDUCTOR SAVINGS & INVESTMENT PLAN APPLICATION FORM

CONDUCTOR SAVINGS & INVESTMENT PLAN APPLICATION FORM CONDUCTOR SAVINGS & INVESTMENT PLAN APPLICATION FORM AGENCY USE: Agency No. Agency Name OFFICE USE: Savings Plan ZSR Contract No. Client No. Investment Plan ZSS Please complete this application in BLOCK

More information

COMPLETE SOLUTIONS COMPANY PENSION PLAN

COMPLETE SOLUTIONS COMPANY PENSION PLAN PENSIONS INVESTMENTS LIFE INSURANCE COMPLETE SOLUTIONS COMPANY PENSION PLAN APPLICATION DETAILS PLEASE READ THE QUESTIONS CAREFULLY BEFORE ANSWERING THEM AND USE BLOCK CAPITALS. If any item is blank or

More information

APPLICATION FOR MEMBERSHIP

APPLICATION FOR MEMBERSHIP P O Box 1101, Florida Glen 1708 Call centre 0860 00 2108 Fax 011 758 7171 E-ail Bonitas@edschee.co.za APPLICATION FOR MEMBERSHIP A B C D Self-eployed person Individuals, groups/copanies of 2-59 ebers,

More information

CONDUCTOR PERSONAL PENSION PLAN application form

CONDUCTOR PERSONAL PENSION PLAN application form CONDUCTOR PERSONAL PENSION PLAN application form AGENCY Use: OFFICE USE: Agency Name Contract Type Agency No. Policy/Contract No. Client No. Please complete this application in BLOCK CAPITALS and tick

More information

A SPOUSE'S RIGHT TO HEALTH INSURANCE AFTER DIVORCE: A REVIEW*

A SPOUSE'S RIGHT TO HEALTH INSURANCE AFTER DIVORCE: A REVIEW* A SPOUSE'S RIGHT TO HEALTH INSURANCE AFTER DIVORCE: A REVIEW* Without proper planning and advice, losing health insurance is a real risk for a divorcing spouse who relies on the other spouse for coverage.

More information

PERSONAL INCOME PROTECTION APPLICATION

PERSONAL INCOME PROTECTION APPLICATION PROTECTION PERSONAL INCOME PROTECTION APPLICATION Adviser s Name: Agency No.: Please tick (3) where appropriate Please ensure that all questions are answered to prevent any delay in the assessment of your

More information

The ITC SSAS APPLICATION PACK. www.independent-trustee.com

The ITC SSAS APPLICATION PACK. www.independent-trustee.com APPLICATION PACK www.independent-trustee.com Application Form Personal Details Title Surname Marital status First name Date of Birth Gender (If divorced, please provide a copy of the Pension Adjustment

More information

Complete Solutions Personal Retirement Savings Account

Complete Solutions Personal Retirement Savings Account Complete Solutions Personal Retirement Savings Account Customer Application Booklet Please ensure you read all declarations carefully before signing Product Selection Personal Retirement Savings Account

More information

Life Cover and Income Protection Schemes

Life Cover and Income Protection Schemes Life Cover and Income Protection Schemes Application form Special offer for IMO Members Group PHI and Life Cover - reduced medical questions Your commitment to provide honest and complete information to

More information

3706JK K925 11/16/2015 12:59:31 PM V 11-6.5 71302 PAGE 4

3706JK K925 11/16/2015 12:59:31 PM V 11-6.5 71302 PAGE 4 For 99 (211) Page 2 Part III Stateent of Progra Service Accoplishents Check if Schedule O contains a response to any question in this Part III 1 Briefly describe the organization's ission: ATTACHMENT 1

More information

Personal Retirement Bond Application Form

Personal Retirement Bond Application Form Personal Retirement Bond Application Form SECTION A: PRB HOLDER DETAILS First Name: Surname: Title: Address: Date of Birth: Email Address: Phone No: PPS/Tax Reference Number (evidence required): Marital

More information

Claim form for a motor vehicle/motorcycle accident

Claim form for a motor vehicle/motorcycle accident Clai or or a otor vehicle/otorcycle accident To be copleted by ENNIA advisor policy. custoer. agent nae agent. nae advisor advisor. phone advisor phone agent clai. Policyholder private individual aily

More information

Absence from Work / Accidental Injury - Claim Form

Absence from Work / Accidental Injury - Claim Form Protection Absence from Work / Accidental Injury - Claim Form Please answer the following questions fully to avoid delay in considering your claim. If you fail to disclose all relevant information or if

More information

Pension Guaranteed Term Protection - Personal. Customer Guide

Pension Guaranteed Term Protection - Personal. Customer Guide Pension Guaranteed Term Protection - Personal Customer Guide Introduction This guide applies to the Zurich Life Pension Guaranteed Term Protection - Personal Plan. Zurich Life Assurance plc ( Zurich Life

More information

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

- 265 - Part C. Property and Casualty Insurance Companies

- 265 - Part C. Property and Casualty Insurance Companies Part C. Property and Casualty Insurance Copanies This Part discusses proposals to curtail favorable tax rules for property and casualty ("P&C") insurance copanies. The syste of reserves for unpaid losses

More information

Name of Employer: Your Work Address:

Name of Employer: Your Work Address: TIE INSURANCE COPANY GEORGIA GROUP INSURANCE EPLOYEE ENROLLENT OR Instructions for completing this enrollment form 1) Each eligible employee enrolling for any coverage offered must complete the entire

More information

NEVADA GROUP INSURANCE EMPLOYEE ENROLLMENT FORM

NEVADA GROUP INSURANCE EMPLOYEE ENROLLMENT FORM NEVADA GROUP INSURANCE EPLOYEE ENROLLENT OR Instructions for completing this enrollment form 1) Each eligible employee enrolling for any coverage offered must complete the entire enrollment form, except

More information

Personal Account Application Form Sole Personal Current Account PLEASE COMPLETE IN BLOCK CAPITALS

Personal Account Application Form Sole Personal Current Account PLEASE COMPLETE IN BLOCK CAPITALS Personal Account Application Form Sole Personal Current Account PLEASE COPLETE IN BLOCK CAPITALS For Bank Use Only Current Account: NSC 9 0 A/c No. Purpose of A/c (andatory: Box must show an understanding

More information

Shepherds Simple Income Protection Plan

Shepherds Simple Income Protection Plan Mutual Solutions. Mutual Benefits. Your Future. Shepherds Simple Income Protection Plan Application Form PLEASE COMPLETE IN BLOCK CAPITALS AND ANSWER ALL QUESTIONS A Life Assured details 1 Have you previously

More information

HDFC Life New Immediate Annuity Plan

HDFC Life New Immediate Annuity Plan VER - 2 HDFC Life New Immediate Annuity Plan Guidelines for filling up the form This form is to be filled by the Proposer himself in BLOCK LETTERS in BLACK INK. Please tick boxes where appropriate. Please

More information

Copy of the Life Insured s/payor s (for Payor Benefit)/ Child (For Serious Illness of a Child Benefit)) Identity Card/Birth Certificate/ Passport

Copy of the Life Insured s/payor s (for Payor Benefit)/ Child (For Serious Illness of a Child Benefit)) Identity Card/Birth Certificate/ Passport Dear Claimant We are sorry to learn of your illness/ injury. In order for us to process the claim, we require the following: 1. Critical Illness Form 2. Attending Physician s Statement 3. Copy of the Life

More information

Application Form Tele-Interview

Application Form Tele-Interview Application Form Tele-Interview Income protection from the original provider If you are medically unable to undertake a telephone interview then do not complete this application process. Please contact

More information

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company

SECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au

More information

Shepherds Simple Income Protection Plan

Shepherds Simple Income Protection Plan Company name: Adviser name: Advised sale: Please choose delivery option: Original policy emailed to client plus copy to adviser Original policy plus copy emailed to adviser only Shepherds Simple Income

More information

A WISER Guide. Financial Steps for Caregivers: What You Need to Know About Money and Retirement

A WISER Guide. Financial Steps for Caregivers: What You Need to Know About Money and Retirement WISER WOMEN S INSTITUTE FOR A SECURE RETIREMENT A WISER Guide Financial Steps for Caregivers: What You Need to Know About Money and Retireent This booklet was prepared under a grant fro the Adinistration

More information

Applying for a passenger service licence

Applying for a passenger service licence Applying for a passenger service licence To operate a goods, passenger, vehicle recovery or rental service the law requires individuals or copanies to hold the appropriate transport service licence. This

More information

Customer Name: Telepak Networks, Inc. Attachment 2 - PreOrdering, Ordering and Maintenance and Repair

Customer Name: Telepak Networks, Inc. Attachment 2 - PreOrdering, Ordering and Maintenance and Repair BELLSOUTH Telepak Networks, Inc.-MBR 3Q06 General Ters and Conditions Table of Contents Signature Page Attachent 1 - Services Attachent1-ExhibitA / CLEC Agreeent Attachent 2 - PreOrdering, Ordering and

More information

SELF-DIRECTED RETIREMENT SAVINGS PLAN APPLICATION

SELF-DIRECTED RETIREMENT SAVINGS PLAN APPLICATION SELF-DIRECTED RETIREMENT SAVINGS PLAN APPLICATION CALEDON TRUST COMPANY LIRA Locked in Retirement Account* LRSP Locked in Retirement Savings Plan* RSP - Retirement Savings Plan - Member Plan RSP - Retirement

More information

Form 990 (2011) Page 2

Form 990 (2011) Page 2 2/13/14 2/13/14 For 99 (211) Page 2 Part Stateent of Progra Service Accoplishents Check if Schedule O contains a response to any question in this Part 1 Briefly describe the organization's ission: ATTACHMENT

More information

Personal Account Application Form Joint Personal Current Account PLEASE COMPLETE IN BLOCK CAPITALS

Personal Account Application Form Joint Personal Current Account PLEASE COMPLETE IN BLOCK CAPITALS Personal Account Application Form Joint Personal Current Account PLEASE COPLETE IN BLOCK CAPITALS IPORTANT NOTE: This Authorisation and Application Form is only appropriate for requests to open a joint

More information

Generali PanEurope Group Income Protection

Generali PanEurope Group Income Protection Generali PanEurope Group Income Protection EmployeE CLAIM FORM AND GUIDE TO THE Claims Process 2 Group Income Protection Employee Guide to the Claims Process Group Income Protection is designed to provide

More information

INSTANT SAVER 2 ACCOUNT

INSTANT SAVER 2 ACCOUNT INSTANT SAVER 2 ACCOUNT Provided by Scottish Widows Bank APPLICATION FORM This form is only for the use of personal customers. Account Number (For office use only) Please complete this form in BLOCK CAPITALS

More information

Joining Worldwide Health Options Your Application

Joining Worldwide Health Options Your Application Joining Worldwide Health Options Your Application iportant inforation To join Bupa siply coplete the questions on this for. Please write clearly in BLOCK capitals using black ink. Once copleted, you can

More information

FTSE 100 Tracker Fund ISA Application Provided by RBS Collective Investment Funds Ltd

FTSE 100 Tracker Fund ISA Application Provided by RBS Collective Investment Funds Ltd FTSE 100 Tracker Fund ISA Application Provided by RBS Collective Investment Funds Ltd p Your information For details of how we and others will use your information and how to give your consent, please

More information

Further Advance. Application Form

Further Advance. Application Form Further Advance Application Form FINANCIAL AVISER Where this application is being submitted through a Financial Adviser, please complete the following details to ensure that the business is allocated to

More information

NEW CLIENT DOCUMENTATION PACKAGE

NEW CLIENT DOCUMENTATION PACKAGE NEW CLIENT DOCUMENTATION PACKAGE Find enclosed herewith our company formation questionnaire and related documentation required to commence a business relationship with St. George s Services Limited. This

More information

APPLICATION FORM. / / / PENSION ANNUITY. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL

APPLICATION FORM. / / / PENSION ANNUITY. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL PENSION ANNUITY APPLICATION FORM. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL We will already have sent you a quote(s), illustrating the

More information

Personal Accident Claim Form

Personal Accident Claim Form Personal Accident Claim Form Claimant Details Title Full Name Date of Birth Occupation Usual Country of Domicile Claimant Address: Contact Details Postcode: Daytime Telephone: Email Address: Wherever possible

More information

BMW Motorrad Unemployment Claim Form

BMW Motorrad Unemployment Claim Form BMW Motorrad Unemployment Claim Form IMPORTANT INFORMATION WHEN MAKING A CLAIM Incomplete claim forms may cause delay in the assessment of your claim. If you are a company employee please send either an

More information

DIRECT TRANSFER ACCOUNT 2

DIRECT TRANSFER ACCOUNT 2 DIRECT TRANSFER ACCOUNT 2 Provided by Scottish Widows Bank APPLICATION FORM Account Number (For office use only) Please complete this form in BLOCK CAPITALS and in ink. APPLICATION CHECKLIST In order for

More information

Close Asset Management (UK) Limited

Close Asset Management (UK) Limited Close Asset Management (UK) Limited X Share Class Unit Trust/OEIC & ISA Application Form This share class is available to investment advisers providing fee-based advice to underlying investors, distribution

More information

AVIVA LTD 4 Shenton Way #01-01, SGX Centre 2, Singapore 068807 Telephone: 6827 7988 Fax: 6827 7900 Company Reg. No. 196900499K

AVIVA LTD 4 Shenton Way #01-01, SGX Centre 2, Singapore 068807 Telephone: 6827 7988 Fax: 6827 7900 Company Reg. No. 196900499K DEATH CLAIM - CLAIMANT S STATEMENT Documents Required: Dear Claimant We re sorry to receive notice of the death claim. To enable us to process your claim, please follow the instructions provided below:

More information

METLIFE EXCEPTED GROUP LIFE POLICY TECHNICAL GUIDE

METLIFE EXCEPTED GROUP LIFE POLICY TECHNICAL GUIDE METLIFE EXCEPTED GROUP LIFE POLICY TECHNICAL GUIDE This document is a guide to the features, benefits, risks and limitations of the MetLife Excepted Group Life policy, including how the policy works and

More information

THE GHC FOUNDATION SIPP

THE GHC FOUNDATION SIPP THE GHC FOUNDATION SIPP APPLICATION FORM GHC Foundation SIPP is operated by Intelligent Money, authorised and regulated by the Financial Conduct Authority FCA number 219473 and registered in England and

More information

Elite Retirement Account

Elite Retirement Account Elite Retirement Account Application Form and Mandate for a Self Invested Personal Pension Plan Member Bank Account Self Invested Personal Pension Scheme Account Opening Request To: The Manager, Partnerships

More information

BIRLA SUN LIFE INSURANCE COMPANY LIMITED CLAIMANT S STATEMENT FORM (DEATH CLAIMS)

BIRLA SUN LIFE INSURANCE COMPANY LIMITED CLAIMANT S STATEMENT FORM (DEATH CLAIMS) BIRLA SUN LIFE INSURANCE COMPANY LIMITED CLAIMANT S STATEMENT FORM (DEATH CLAIMS) Points to Note This form is to be filled in by the beneficiary under the policy or by the person legally entitled for the

More information

POLICY CONDITIONS Conductor Personal Pension Plan (PC CPPP 06/11)

POLICY CONDITIONS Conductor Personal Pension Plan (PC CPPP 06/11) POLICY CONDITIONS Conductor Personal Pension Plan (PC CPPP 06/11) Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Contract and definitions Contributions The funds Unit linking Benefits General

More information

Dual Enrollment Application for Admission For High School Juniors and Seniors

Dual Enrollment Application for Admission For High School Juniors and Seniors Application for Adission www.colubiastate.edu Office of Adissions 1665 Hapshire Pike Colubia, TN 38401 Dual Enrollent Application for Adission For High School Juniors and Seniors How do I apply? Step 1

More information

Junior Gold, Class C Shares (ISIN Accumulation GB00B39RN474) This fund is managed by Marlborough Fund Managers Ltd

Junior Gold, Class C Shares (ISIN Accumulation GB00B39RN474) This fund is managed by Marlborough Fund Managers Ltd Key Investor Information This document provides you with key investor information about this fund. It is not marketing material. The information is required by law to help you understand the nature and

More information

Switching your personal current account made easy

Switching your personal current account made easy Switching your personal current account made easy Introduction Summary of the Key Features of the Account Switching Code Bank of Ireland ( New Bank ) can facilitate all of the steps required in order to

More information

gold account application form

gold account application form gold account application form This form is for individual applicants only. For company giving, please download a corporate giver application at stewardship.org.uk/company. Please complete in BLOCK CAPITALS,

More information

APPLICATION & INCOME PAYMENT FORM FOR ANNUITY QUOTATION REF: A Q INCLUDING EXISTING PRUDENTIAL PENSION FUND(S)

APPLICATION & INCOME PAYMENT FORM FOR ANNUITY QUOTATION REF: A Q INCLUDING EXISTING PRUDENTIAL PENSION FUND(S) APPLICATION & INCOME PAYMENT FORM FOR ANNUITY QUOTATION REF: A Q INCLUDING EXISTING PRUDENTIAL PENSION FUND(S) Please add the full reference for the annuity you are accepting. Please use black ink and

More information

Applications accepted by email to queries@lia.ie or by Fax to 01 4554530 or by Post to LIA, 183 Kimmage Road West, Dublin 12.

Applications accepted by email to queries@lia.ie or by Fax to 01 4554530 or by Post to LIA, 183 Kimmage Road West, Dublin 12. APA () Designation Application Form (Transition Period 1st Nov 2011 31st Dec 2012) Please use BLOCK CAPITALS. Complete the sections of the application form AS INDICATED, and ensure you SIGN and DATE the

More information

THE ITC BUY OUT BOND BROCHURE. www.independent-trustee.com

THE ITC BUY OUT BOND BROCHURE. www.independent-trustee.com THE ITC BUY OUT BOND BROCHURE www.independent-trustee.com If you were the member of an occupational pension scheme, leaving or have left employment, or your pension scheme is being wound up, it is time

More information

Insurance Transfer Form Russell SuperSolution Master Trust Private Division

Insurance Transfer Form Russell SuperSolution Master Trust Private Division Insurance Transfer Form Russell SuperSolution Master Trust Private Division If you hold insurance cover in another superannuation fund or directly with another life insurer, you can apply to transfer your

More information

Use a separate piece of paper if you need any more space for any of your answers but please sign and date it.

Use a separate piece of paper if you need any more space for any of your answers but please sign and date it. Alteration Form NOTES Please read these notes carefully before completing the application form. Please make sure that you: Use blue or black ink; Use BLOCK CAPITALS throughout; Correct and initial any

More information

Guaranteed Whole of Life Protection. Customer Guide

Guaranteed Whole of Life Protection. Customer Guide Guaranteed Whole of Life Protection Customer Guide Introduction This guide applies to Eagle Star s Guaranteed Whole of Life Plan. Eagle Star wants to make sure that you purchase a policy that meets exactly

More information

GROUP PERMANENT HEALTH INSURANCE

GROUP PERMANENT HEALTH INSURANCE GROUP PERMANENT HEALTH INSURANCE Claim form Note: Please answer all questions carefully. Failure to provide full information may delay claim consideration. Scheme Name University of Limerick PERSONAL DETAILS

More information

Individual Income Protection Insurance Claim Form

Individual Income Protection Insurance Claim Form Individual Income Protection Insurance Claim Form Claimant s Name: Policy Number(s): IMPORTANT INFORMATION: Please read before completing this form. We need the information in this form so that we can

More information

2013/2014 TAX YEAR NEW SUBSCRIPTIONS. Applications must be received by 15 November 2013.

2013/2014 TAX YEAR NEW SUBSCRIPTIONS. Applications must be received by 15 November 2013. Legal & General Defined Return Plan 3 NEW ISA AND/OR DIRECT INVESTMENT APPLICATION FORM. Applications must be received by 15 November 2013. 2013/2014 TAX YEAR NEW SUBSCRIPTIONS FOR OFFICE USE Client Number

More information

10 BASIC PLAN DETAILS (Select any one option by ticking the box) 10.1 Annuity Provider (1)- Share out of 100%- 10.1.1 10.1.2 10.1.

10 BASIC PLAN DETAILS (Select any one option by ticking the box) 10.1 Annuity Provider (1)- Share out of 100%- 10.1.1 10.1.2 10.1. SBI Life - Swarna Jeevan (UIN - N09V0) To be filed in by employee/ nominee Details of the member on whose life annuity is to be effected Name of the Employee: First Name Second Name Last Name. Name of

More information

Group Personal Pension

Group Personal Pension Application Form (For employed or self-employed individuals) Who this form is for When we refer to Standard Life we mean Standard Life Assurance Limited This form is for employees, or self-employed individuals

More information

SUPPORTING YOUR HIPAA COMPLIANCE EFFORTS

SUPPORTING YOUR HIPAA COMPLIANCE EFFORTS WHITE PAPER SUPPORTING YOUR HIPAA COMPLIANCE EFFORTS Quanti Solutions. Advancing HIM through Innovation HEALTHCARE SUPPORTING YOUR HIPAA COMPLIANCE EFFORTS Quanti Solutions. Advancing HIM through Innovation

More information

CATLIN HONG KONG LTD MISCELLANEOUS PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

CATLIN HONG KONG LTD MISCELLANEOUS PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM CATLIN HONG KONG LTD MISCELLANEOUS PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER REGARDING COMPLETION OF THIS PROPOSAL FORM 1) Disclosure Any material fact

More information

Fuelcard Application Form

Fuelcard Application Form Fuelcard Application Form The SMART way to fuel today.. Email: smartcard@emo.ie Company Name Trading Name (if different) Address Company Reg No / VAT No. Number of Years Trading Type of Business Contact

More information

Professional Indemnity Insurance Management Consultants Proposal Form

Professional Indemnity Insurance Management Consultants Proposal Form Professional Indemnity Insurance Management Consultants Proposal Form Towergate Lifestyle Suite 4b, 1 Portland Street, Manchester, M1 3BE Tel: 0844 892 1789 Fax: 0844 892 1796 Email: lifestyle@towergate.co.uk

More information

Important Compliance Information. How to obtain and use the new documents (if fillable PDF s are mentioned above)

Important Compliance Information. How to obtain and use the new documents (if fillable PDF s are mentioned above) Copliance This Copliance is being sent to infor you that one or ore of the docuents currently contained in your Wolters Kluwer Financial Services Bankers Systes software syste or electronic docuents odule

More information

Lump sum benefit payment request for your superannuation or account based pension

Lump sum benefit payment request for your superannuation or account based pension Lump sum benefit payment request for your superannuation or account based pension How to claim a benefit To claim a benefit you will need to complete the attached Benefit Payment Request and send it direct

More information

60 Day Notice Business Savings Account Issue 4-Application Form

60 Day Notice Business Savings Account Issue 4-Application Form 60 Day Notice Business Savings Account Issue 4-Application Form Please complete this form in BLOCK CAPITALS and in ink. Account Number (For bank use only) I/We would like to invest into a 60 Day Notice

More information

Personal Accident/Sickness Claim Form

Personal Accident/Sickness Claim Form Personal Accident/Sickness Claim Form SM THANK YOU FOR NOTIFYING US OF YOUR CLAIM PLEASE COMPLETE ALL QUESTIONS IF ANY QUESTION IS NOT APPLICABLE PLEASE STATE N/A Name of Policyholder Certificate/Policy

More information

PERSONAL ACCIDENT BENEFITS CLAIM FORM

PERSONAL ACCIDENT BENEFITS CLAIM FORM PERSONAL ACCIDENT BENEFITS CLAIM FORM Please note that we have to ensure that our claim form covers all types of claims. If you do not consider a question to be relevant to your circumstances please enter

More information

DIRECTORS AND OFFICERS LIABILITY INSURANCE PROPOSAL FORM

DIRECTORS AND OFFICERS LIABILITY INSURANCE PROPOSAL FORM DIRECTORS AND OFFICERS LIABILITY INSURANCE PROPOSAL FORM In completing the Proposal Form please ensure that questions are answered fully and accurately and where necessary schedules giving further explanation

More information

Multi-Platform International Open Pension. Application Form Connectable, Flexible, Upgradable.

Multi-Platform International Open Pension. Application Form Connectable, Flexible, Upgradable. Multi-Platform International Open Pension Application Form Connectable, Flexible, Upgradable www.londoncolonial.com This application form can be used to establish your Multi-Platform International Open

More information

Trustee training guide for one member plans

Trustee training guide for one member plans Trustee training guide for one member plans Contents Appropriate Trustee Training 2 Trusteeship 3 Investment 5 Member Communication 6 Administration 7 Compliance and Regulation 10 Trustee Declaration

More information

SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM

SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM SPORT / VOLUNTARY WORKERS INSURANCE CLAIM FORM The issue or acceptance of this form is not construed as an admission of liability on the part of the Company. Please print clearly. To avoid delays please

More information

Foundation dentists application form

Foundation dentists application form Foundation dentists application form For all UK applications Important notes: Before completing this application form It is important that you have been given a copy of our key features document and your

More information

Investment Funds ISA Application Form

Investment Funds ISA Application Form Investment Funds ISA Application Form Please select one of the following: Lump sum Regular saver investment Combined lump sum and regular saver investment Before completing this application form please

More information

METLIFE SINGLE LIFE RELEVANT LIFE POLICY TERMS AND CONDITIONS

METLIFE SINGLE LIFE RELEVANT LIFE POLICY TERMS AND CONDITIONS METLIFE SINGLE LIFE RELEVANT LIFE POLICY TERMS AND CONDITIONS Contents 1 The MetLife Single Life Relevant Life policy 4 2 Definitions 4 3 Minimum requirements for the MetLife Single Life Relevant Life

More information

Title: Mr Mrs Ms Others... Family Name (in block letters):... First Names (in block letters):... NIC No:...Nationality:...

Title: Mr Mrs Ms Others... Family Name (in block letters):... First Names (in block letters):... NIC No:...Nationality:... Business Credit Card Application Form (Nominee) Nominee Details Title: Mr Mrs Ms Others... Family Name (in block letters):... First Names (in block letters):... Embossing name on card (in block letters

More information

Option B: Credit Card Processing

Option B: Credit Card Processing Attachent B Option B: Credit Card Processing Request for Proposal Nuber 4404 Z1 Bidders are required coplete all fors provided in this attachent if bidding on Option B: Credit Card Processing. Note: If

More information

UltraCare International Schools plan Individual application Moratorium

UltraCare International Schools plan Individual application Moratorium UltraCare International Schools plan Individual application Moratorium Need help completing this application? Please contact either your advisor or us directly. You can find our contact details on our

More information

SME Business Lending. Application Form Republic of Ireland. www.bankofireland.com/business

SME Business Lending. Application Form Republic of Ireland. www.bankofireland.com/business SME Business Lending Application Form Republic of Ireland www.bankofireland.com/business Bank of Ireland is regulated by the Central Bank of Ireland. CONTENTS PART 1 PART 2 PART 3 PART 4 (i) PART 4 (ii)

More information

Investment trust application forms

Investment trust application forms Investment trust application forms 2015/2016 Form A Application for a 2015/2016 tax year stocks and shares ISA Form B Application to transfer an existing stocks and shares ISA Form C Application to transfer

More information

Income Continuance Plan For staff members of the University of Limerick (UL)

Income Continuance Plan For staff members of the University of Limerick (UL) Income Continuance Plan For staff members of the University of Limerick (UL) Standard application form Eligibility - please note that members must be under age 65 To be eligible to apply for membership

More information

Submit the following. Application Form. Complete in full and sign. Please ensure that all declarations are signed and fully completed

Submit the following. Application Form. Complete in full and sign. Please ensure that all declarations are signed and fully completed Personal Loan 3 simple steps to applying for a KBC Personal Loan (Tick when complete) 3 Complete this checklist In order to consider your application for a KBC Personal Loan, please confirm the following:

More information

ANZ Superannuation Savings Account Life Insurance Application Form

ANZ Superannuation Savings Account Life Insurance Application Form 12 March 2014 Customer Services Phone 13 38 63 Fax 02 9234 6668 Email customer@onepath.com.au Website anz.com Note: Please ensure you complete all details on this form. Any missing details will delay your

More information

LIFE INSURANCE CLAIM APPLICATION FORMS

LIFE INSURANCE CLAIM APPLICATION FORMS LIFE INSURANCE CLAIM APPLICATION FORMS INSTRUCTIONS ALL OF THE FOLLOWING PROPERLY COMPLETED FORMS ARE ESSENTIAL TO THE PROMPT PROCESSING OF YOUR CLAIM: INFORMATION RELEASE FORMS (Please complete both Information

More information

Insurance request VicSuper FutureSaver

Insurance request VicSuper FutureSaver GPO Box 89 Melbourne Vic 3001 VicSuper Member Centre 1300 366 216 vicsuper.com.au Insurance request VicSuper FutureSaver * Indicates that providing this information is mandatory. Not doing so may delay

More information

International Healthcare Plan Application Form

International Healthcare Plan Application Form International Healthcare Plan Application orm Aetna Global Benefits Please read through the following before completing this application and complete in BLOCK CAPITALS. All information supplied will be

More information

AVIVA INVESTORS INVESTMENT ISA APPLICATION FORM 2014/2015 Tax year

AVIVA INVESTORS INVESTMENT ISA APPLICATION FORM 2014/2015 Tax year AVIVA INVESTORS INVESTMENT ISA APPLICATION FORM 2014/2015 Tax year Please answer all questions in CAPITAL LETTERS and tick boxes where appropriate. Once you have completed this application form, please

More information

PERSONAL ACCIDENT AND/OR SICKNESS CLAIM FORM

PERSONAL ACCIDENT AND/OR SICKNESS CLAIM FORM We are pleased to enclose a claim form as requested. PERSONAL ACCIDENT AND/OR SICKNESS CLAIM FORM Most delays in settling claims arise because claim forms are not fully completed or requested documents

More information

Application for Fixed and Life Annuity For registered and non registered contract

Application for Fixed and Life Annuity For registered and non registered contract POU Client Services Tel. 506-853-6040/1-888-577-7337 Fax 506-853-9369/1-855-577-3864 financial.services@assumption.ca Application for Fixed and Life Annuity For registered and non registered contract 1.

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Injury Claim Form Sports Underwriting Australia Claims Department PO Box 2717, Taren Point. NSW, 2229 Tel: 1300 363 413 Fax: 02 9524 9003 Email: sua@au.innovation-group.com Members Name: Address:

More information

Income Protection Plan for National University of Ireland, Galway (NUIG) employees Standard application form

Income Protection Plan for National University of Ireland, Galway (NUIG) employees Standard application form Income Protection Plan for National University of Ireland, Galway (NUIG) employees Standard application form Eligibility For use only by members under age 65 To be eligible to apply for membership of the

More information

Switching your Business Current Accounts

Switching your Business Current Accounts Switching your Business Current Accounts Summary of the Key Features of the Account Switching Code for Business customers Bank of Ireland ("New Bank") can facilitate all the steps required in order to

More information