COLONIAL INSURANCE APPLICATION

Transcription

1 LIFE INSURANCE APPLICATION COLONIAL INSURANCE APPLICATION A Member of the BSP Group Please Please check complete all details, relevant then areas complete of the the form, relevant check areas all of details the form and and return return it it to to: : BSP New Life Business (Fiji) Limited, Department, GFL BSP Colonial, Life Centre, Private Thomson Mail Bag, Street, Suva, Private Fiji Mail Islands Bag, Telephone: Suva, Fiji Facsimile: (679) Website: www Telephone: Call Centre: Facsimile: Web: PLEASE COMPLETE ALL DETAILS IN BLOCK LETTERS POLICY OWNER(S) 1. Mr/Mrs/Miss/Ms Father s Name Mailing Address Given Names Surname Telephone Home Work Mobile Address 2. Mr/Mrs/Miss/Ms Father s Name Mailing Address Telephone Home Work Mobile Address LIFE TO BE INSURED Mr/Mrs/Miss/Ms Previous Name (if changed) Home Address Given Names Surname Father s Name Contact details Home Work Address of Birth / / Age next Birthday Sex Male Female Marital Status Single Married Relationship to the Proposer Occupation Nature of Duties Employer/Group Period of Employment Current Previous Annual Salary before Tax $ Payment Frequency Weekly Fortnightly Monthly Semi-Monthly Quarterly Half Yearly Yearly BENEFIT DETAILS Name of Benefit eg. Bula Scholar Benefit Code eg. ED1 Policy Term Sum Insured Yearly Premium Instalment Premium Attachable Benefit Add Administration Fee Total Premium Vanishing Premium (Definition Refer page 6) Extended Term Insurance n-smoker Rates ( Only available for Bula Flexi Plus) Payment Direct to BSP Life (Please make cheques payable to BSP Life. Cheques should be marked not negotiable. to be made Group Deduction Group Name Pay /FNPF (Please complete and attach a Group Deduction Authority if applicable) Bank Name of Bank Account Name Account Number (Please complete and attach a Bank Deduction Authority if applicable)

2 PERSONAL STATEMENT (to be completed by the Life to be Insured) We understand that the medical questions we ask in this section may be sensitive, but it is very important that you give us all the information that may affect your application for insurance. If you prefer, you can complete this form in private and post it directly to BSP Life, New Business Department at Private Mail Bag, Suva, Fiji Islands. If you answer YES to any of the questions below please provide the details in the space provided. Please give as much detail as possible including details of any medical condition, treatment, dates and results. PART A 1. Do you have or are you currently applying for any other Life or Health insurance cover or for the reinstatement of a policy on your life with BSP Life or any other company? If yes, please give details. 2. Has any insurance (or an application for the reinstatement of a policy) on your life with BSP Life or any other company ever been cancelled, deferred, declined, accepted with extra premium or on special terms other than proposed? Office Policy. Life Sum Insured Accident Sum Insured Please give details or complete on separate form and attach to application if more space is required. 3. Have you engaged in or do you intend engaging in Aviation other than as a fare-paying passenger on a recognised Passenger air service? 4. Have you engaged in or do you intend engaging in Boxing, Racing (other than on foot), Parachuting, Skydiving, Hang-gliding, Scuba Diving or Motor Sports? 5. (i) Have you ever resided or engaged in War service in any other country? (ii) Was your health affected as a result? 6. Do you contemplate residing in another country? Please complete an Aviation Supplementary Personal Statement Please complete a Hazardous Activities Supplementary Personal Statement Please give details Please give details Please give details 7. (i) Who is your usual Doctor? Name Mailing Address (ii) Please give details of any medical professional or clinic you have consulted in the last 5 years Name of Medical Professional/Clinic Reason Treatment PART B 8. (a) Do you take alcohol (b) Do you take kava? (c) Do you smoke? (d) if no to (c), have you ever smoked? Please give details Type Daily Quantity Please give details Daily Quantity Please give details Type Daily Quantity Please give details Ceased Reason 9. What is your height Height cm/ft Weight kgs/lbs and weight? Has your weight altered in the last 12 months? Reason Please give reasons Increase kgs/lbs Decrease kgs/lbs 2

3 10. Have you suffered from or received advice, treatment or medication on or experience any symptom or sign of any of the following from a health professional or an institution: If you answer YES, please complete a Supplementary Personal Statement Form. (a) Chest pain or discomfort, abnormal palpitation of the heart, heart attack, shortness of breath, fainting episodes, high blood cholesterol or any other heart complaint or disease. (b) Epilepsy, neurological diseases, mental or nervous disorders e.g. Sclerosis, paralysis, anxiety, depression, stress? (c) Diseases or disorders of the eyes, ears, nose or throat including sinusitis, recurrent sore throat, tonsillitis or ear infections? (d) Any ailments or diseases pertaining to the Lungs, Stomach, Liver, Kidneys, Bladder, Uterus, Scrotum or any disorders or diseases of the reproductive system, Bowel, Liver or Gall Bladder, or Pancreas? (e) Diabetes, gout, thyroid disorders, high blood pressure, low blood pressure, hypertension or rheumatic fever/ heart disease. (f) Arthritis, rheumatism or disorder or diseases or injury to muscles, bones or joints. (g) Cancer, tumor, cyst, abnormal cervical smear, breast lump, moles, skin disorders or any other abnormal growth or abnormal bleeding or discharge from any part of your body. (h) Varicose veins, hemorrhoids or any other form of blood or blood vessel disorders? (i) (j) Any sexually transmitted infections, AIDS or AIDS related conditions and antibodies? Night sweats, inexplicable weight loss, persistent fever, diarrhoea or swollen glands? (k) Any other illness, injury, operation, disability or physical abnormality? 11. Have you ever been refused as a blood donor or have received or treated with blood or blood products or had an organ transplant, whether be a donor or receptor? If YES, please give details. 12. Have you ever had any medical examination, advice, treatment, surgical operation, x-ray, electrocardiogram (ECG), CT Scan, MRI or any other test or investigation not disclosed in Questions 10 or 11, or have taken any medication or drug by mouth or injection other than for cough, colds or influenza? If you answer YES, please complete the Schedule below: SCHEDULE FOR QUESTIONS 10, 11 AND 12 Name Name and Address of Doctor, Hospital, etc. Reason treatment undergone, result of any test or x-ray, date of complete recovery. Show details of any medication under Q.12 Duration Time Off Work 13. Have any of your parents, brothers or sisters died or suffered from heart disease including cardiomyopathy, stroke, high blood pressure, diabetes, kidney disease, cystic fibrosis, cancer, mental disorder, muscular dystrophy or, partners or spouses from tuberculosis, hepatitis, AIDS or AIDS related conditions? Please give details Family Member/Spouse or Partners Condition State of Health Age at Diagnosis Age at Death FOR FEMALES ONLY 14. (i) Are you pregnant? Please give details Expected Delivery (ii) Have you had any Pap Smear or mammogram? Please give details of Test Result (iii) Are you suffering from any medical condition induced by this pregnancy? Please give details 33

4 NON SMOKER DECLARATION This Section is to be completed if applying for n-smoker Premium Rate (only available for Bula FLEXI PLUS) I declare that I have smoked NO cigarettes, cigars, piped tobacco or any other form of tobacco in the past twelve months, and that I have NO intention of smoking cigarettes in the future. I understand that any omission or mis-statements in this declaration could cause an otherwise valid claim to be denied under any Policy issued as a result of this Application. of Life to be Insured: : (This declaration, if made, must be signed by the insured) Name and of Witness: : This declaration, if made, must be signed by the Life To Be Insured SALES ADVISORS/THIRD PARTY DECLARATION IMPORTANT NOTICE This declaration must be completed if this application form has been filled in by a BSP Life Insurance Agent or, any other than the Life to be Insured/Policy Owner. 1. I of occupation certify that the Life to be Insured/Policy Owner was unable to fill in this application on the Life to be Insured/Policy Owner s behalf. 2. I certify that the information given to me by the Life to be Insured/Policy Owner has been accurately and honestly recorded by me in this application form. 3. I certify that the information filled out in this application form has been read back to the Life to be Insured/Policy Owner and explained to him/her in the English/Fijian/Hindi/Chinese/Other language and the Life to be Insured/Policy Owner understands its content thereof. Name and of BSP Life Insurance Advisor/Third Party Name and of Witness DECLARATION AND CONSENT IMPORTANT NOTICE Your duty of Disclosure Before you enter into this contract of Insurance ( Insurance ) you have a duty to disclose to BSP Life (Fiji) Limited ( BSP Life ) every matter that you know or could reasonably be expected to know which is relevant to its decision whether to accept the risk of the Insurance and if so on what terms. You have the same duty to disclose those matters to BSP Life before you apply to vary or reinstate the Insurance. If you fail to comply with your duty of disclosure to BSP Life and it would not have issued the insurance on the same items if disclosure had been made, BSP Life may cancel and void the insurance from inception. The below named Life to be Insured and Policy Owner(s) declare and agree that 1. The above answers have been entered by me/us and have been checked by me/us. 2. I hereby declare that the Agent has fully explained the contents and questions of this application to me and that he has recorded the replies as per my dictation. I further declare that I have signed the application form only after ensuring that I have understood its contents and the replies have been correctly recorded therein. 3. I/We have read the notice explaining my/our duty of disclosure and all the statements contained in this Application are true and complete to the best of my/our knowledge. 4. Should the Life to be insured undergo any alteration in mental or physical health or have a change of occupation between the date of this Application and the issue of the Insurance, I/We agree to notify BSP Life immediately as this information is relevant to any decision BSP Life may make to accept this Application. 5. I/We understand that any statements made in this Application including any statements made by me/us to any medical examiner or made by any medical examiner on my/our behalf will form the entire basis of an insurance contract between me/us and BSP Life. 6. I/We understand the Insurance proposed in this Application WILL NOT COMMENCE until this Application has been accepted by BSP Life and the initial premium has been received by BSP Life. 4

5 7. I/We will be bound by the standard conditions applicable to the proposed Insurance upon BSP Life s acceptance of this Application. 8. Tick only one of a or b a. I/We agree that the information contained in this Application be disclosed to other entities within, or managed by BSP Life for the purpose of marketing to me/us products offered from time to time by BSP Life and authorise those other entities to seek access to that information. b. do not agree that the information contained in this Application be disclosed to other entities within, or managed by, BSP Life. 9. I/We acknowledge that I/we have disclosed all health information, including any pre-existing conditions for me/ourselves. OR 10. I/We understand that this Application does not cover any benefit payable in the event of death or disability occurring from war or war service, however defined and including war against terrorism whether war be declared or not, or warlike operation, or civil or political commotion or civil or political unrest or terrorist attack. 11. I/We authorize BSP Life to seek from: Registered Medical Practitioner and Specialists Dentists Counsellors, psychologists and therapists Insurers (whether public or private) Hospitals (whether public or private) I/We agree that a photocopy of this authority will be valid as an original. of Life to be Insured Or Left/Right Thumb Print of Witness of Policy Owner 1 or Left/Right Thumb Print - Policy Owner (1) of Witness of Policy Owner 2 or Left/Right Thumb Print - Policy Owner (2) of Witness To be completed if the proposer is Under the age of 18 I consent to this insurance. Consent signified by (Parent/Guardian) of Witness - of Parent/Guardian 5

6 NOMINATION OF BENEFICIARY (NOTE: If the Beneficiary is under 21 years old a Trustee mination Form must also be completed). In accordance with Section 152 of the Fiji Insurance Act, 1998, I hereby nominate the following person/people as beneficiary(ies) in the event of my death. Name Age Relationship Father s Name % of Policy Owner 1 of Witness of Policy Owner 2 of Witness Definition Vanishing Premium: An option which can be selected at any stage during the premium paying period. However, the feature can only be effected at a point in time when sufficient bonus has accrued such that its cash value is sufficient to offset all future premiums payable. Extended Term Insurance: The cash value (net of all debts) is used to purchase a paid up term insurance, with the same sum insured as the original basic plan at the attained age of the insuredat the time the option was availed of. The option changes the cover to a paid up term insurance cover. 6 6

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8 TO BE COMPLETED BY YOUR BSP LIFE SALES AGENT. Sales Agent Name Agency Number Sales Unit Quality Rating Deposit Premium Details Cheque no. ( ) Paid at on / / Cash ( ) on / / Do you expect that this insurance will replace all or part of an existing policy or proposal or one discontinued within the last 12 months? If YES, please give the previous policy/proposal number and the reasons for replacement. I hereby certify that to the best of my knowledge I have explained to the Policy Owner all the benefits proposed, the questions on this form, and the importance of this application. of Sales Agent : NOTES of DSM/General Agent : Policy Document to be Personally Delivered Posted FOR OFFICE USE ONLY Receipt. Paid Amount Proposal. EXISTING POLICY DETAILS (For Waiver or Life Insured) Policy. Personal or Benefit Code Life Sum Attached Benefit N/M Loading or Keyman Insured Sum Insured Exclusion Action Initial Proposal Signed ASSESSMENT PANEL Age Admit Commencement Reass Indic MIC Application Received CLAS Searched CLAS Entered Assessment Entered Policy Printed Policy Checked Policy Dispatched Application Cancelled Product Rating Code Initial & Basic TR ADB TPD CI WAIVER Other Specify SPECIAL CONDITIONS/EXCLUSIONS Reinsurance Details: Acceptance : Assesment Number: Client ID Number: 8 UWG /12