Group Income Protection Insurance - KPMG Employer s Questionnaire

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1 Group Income Protection Insurance - KPMG Employer s Questionnaire Employee Name Please complete all sections as fully as possible using black ink. You can attach separate sheets, as necessary. If you are in any doubt as to whether you need to disclose a particular fact to us, please state it in full. Once completed and signed, please post this questionnaire, together with the following items, to us at: Claims Dept, Unum, Milton Court, Dorking, Surrey, RH4 3LZ. Alternatively them to us at 1. Job Description 2. Absence records for the two year period prior to the employee s absence 3. An original birth certificate if the age of the employee has not been admitted for employment or pension purposes 4. A marriage certificate if the employee is a married female. Timetable for submission of claims: 13 week deferred period - no more than 4 weeks after incapacity begins a deferred period of more than 13 weeks - no more than 10 weeks after incapacity begins Should you have any queries, please contact us on Please note: As part of the claims assessment process, one of our Claims Management Specialists may telephone the claimant directly. The purpose of this contact is to gather information to assist with the early delivery of a decision. Please be assured that no payment details will be discussed. Our Rehabilitation and Health Management Team may be able to help your employee to return to work. We can guide you on reasonable adjustments where these are needed and we can help you build vocational rehabilitation plans. If it is appropriate, our Rehabilitation and Health Management Team may contact you regarding the services we can provide. Alternatively, you can call our Rehabilitation and Health Management Team on to discuss the support available to you and your employee. page 1 of 8 UP333a KPMG 11/2014

2 Section 1 - Eligibility Details Life ID (if known) Policy Number Name of scheme KPMG UK Limited Contact Name Company Address Postcode Contact Telephone Number Contact Employee Name Employee Address Date of Birth Postcode Employee Telephone Number National Insurance Number If you have confirmed the employee s date of birth for employment or pension scheme purposes, please tick here. Alternatively, please enclose proof of age in the form of your employee s original birth certificate (and marriage certificate if a married female). Date of commencement of continuous absence (dd/mm/yyyy) (please enclose absence record) Salary prior to incapacity (as defined in Scheme s Rules) Date joined company s service (dd/mm/yyyy) Date joined Scheme (dd/mm/yyyy) Has employment been terminated? Yes No If Yes please advise date If No does the job still exist Yes No Is the employee eligible for Private Medical Insurance? Yes No (e.g. BUPA, PPP, AXA, etc) If Yes, at what level? Job grade of employee Branch Location Business Function Audit Tax Central Services Advisory (management consulting) Advisory (risk consulting) Advisory (transactions restructuring) Employee Number Has the member flexed up? Yes No page 2 of 8 UP333a KPMG 11/2014

3 Section 2 - Absence Details Nature of illness/injury/condition (if known) Prior to absence, was the employee able to complete tasks to the required standard? If not, please provide details. Were/are there any performance/disciplinary/attendance issues? If so, please provide details (including absence records) Has the treating medical practitioner indicated whether the employee can return to work on a modified basis? (Please tick below as appropriate) On a phased basis Amended duties Altered hours With workplace adaptations Please give details, including any recommendations for reasonable adjustments or recovery time Has a return to work date been discussed or agreed? page 3 of 8 UP333a KPMG 11/2014

4 Section 2 - Absence Details continued Have adjustments been made to the employee s role? Yes No If Yes, please provide details and indicate whether the adjustments have been successful Has objective testing of the employee s ability to work been carried out by your company/your Occupational Health Provider, etc? Yes No If Yes, please provide details of objective tests (eg Vocational Assessment, Functional Capacity Assessment) Has a home visit been carried out by your company? (e.g. by Human Resources, Occupational Health, Line Manager) Yes No Please provide details of how you would like unum s Rehabilitation and Health Management Services to assist in this case. page 4 of 8 UP333a KPMG 11/2014

5 Section 3 - Occupation Details (to be completed by the employee s line manager) This section contains detailed information of the employee s occupation, including a description of the fundamental duties and demands of the job, as well as details of any adjustments or modifications to those duties. This section should be completed by the employee s line manager, if possible. 1. Details of Employment Name of employer and place of work Telephone number Type of industry Postcode What is the employee s job title? Please describe the required and essential duties of the employee s job in detail, including any special intellectual demands (e.g. communications, calculation, problem solving, etc). Non-essential duties should not be included. Please note: the employer must investigate and implement any reasonable adjustments to the working conditions, the physical features and other arrangements of the employee s occupation which would enable the employee to continue working. The employer must also investigate and, where appropriate, make reasonable efforts to implement any rehabilitation and reintegration programmes to enable the employee to return to work. page 5 of 8 UP333a KPMG 11/2014

6 Section 3 - Occupation Details continued 2. Work environment In what area does the employee work (e.g. office, outdoors, factory, etc)? If more than one, please indicate the percentage of time spent in each area. What machines, tools or special equipment (if any) does the employee operate? Does the job require exposure to dust, fumes, heat or cold, noise or any other specific environmental conditions? Yes No If Yes, please give details Does the job require lone working, working at heights, working in confined spaces or the use of specialised personal protective equipment (e.g. respirators, breathing apparatus, etc)? Yes No If Yes, please give details 3. Physical requirements of job Tick this box if the employee is employed in a 100% white collar, desk based role. If not please provide full details of the physical requirements of the job. Yes No page 6 of 8 UP333a KPMG 11/2014

7 Section 3 - Occupation Details continued 4. Hours of Work What are the employee s normal weekly contractual hours? Total per week Do any of the following apply? From To AM / PM AM / PM Shift Work Yes No Weekend Work Yes No Being on Call Yes No 5. Job Skills Does the employee have management or supervisory responsibilities? Yes No If Yes, how many staff does the employee directly manage/supervise? What qualifications, skills and/or experience are required to perform the occupation? 6. Travel Does the employee s job involve travelling Yes No If Yes, how many miles per week? How does the employee travel? Please attach additional sheets if necessary Section 4 - Payment Details Name and address of the employer s bank to which benefit payments should be made if the claim is admitted Bank Name Name of Company Account Bank Sort Code Barclays Bank KPMG Bank Account No page 7 of 8 UP333a KPMG 11/2014

8 Section 5 - Declarations Check List Please remember to include the following items with this form: 1. Job Description 2. Absence Records 3. Original Birth Certificate (if required) 4. Marriage Certificate (if required) Declaration I declare that all statements made are true and complete to the best of my knowledge and belief and that I have disclosed all information material to this claim for benefit. I understand that if any information provided is found to be deliberately misleading, or if I fail to provide material information, this claim may be rejected and the insurer may be entitled to keep any premiums paid. Signed Date (dd/mm/yyyy) Full name Position in company unum.co.uk Unum Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Registered in England We monitor telephone conversations and communications from time to time for the purposes of training and in the interests of continually improving the quality of service we provide. Copyright Unum Limited 2014 Registered office: Milton Court, Dorking, Surrey RH4 3LZ TEL FAX page 8 of 8 UP333a KPMG 11/2014

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