Group Income Protection Insurance - Employer s Questionnaire Morgan Stanley - Glasgow

Transcription

1 Group Income Protection Insurance - Employer s Questionnaire Morgan Stanley - Glasgow 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 fax this questionnaire, together with the following items, to us on Alternatively, post them to us at: Claims Dept, Unum, Milton Court, Dorking, Surrey, RH4 3LZ. 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 policy 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 6 UP333a MSG 05/2013

2 Section 1 - Eligibility Details Life ID (if known) Name of scheme Contact Name Company Address & Postcode Morgan Stanley UK Limited 55 Douglas Street, Cadogan Square Glasgow, G2 7NP Policy Number Contact Telephone Number Contact Employee Name Employee Address & Postcode Date of Birth 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) Scheme Category Date eligible to join Company Pension Scheme (dd/mm/yyyy) Date joined Company Pension Scheme (dd/mm/yyyy) Has employment been terminated? Yes No If Yes please advise date If No does the job still exist Yes No How long will the role remain open for the employee? At what stage does their salary reduce during absence and to what level? Percentage of pension fund contributions insured % Is National Insurance contracted in or out? In Out Is the employee eligible for Private Medical Insurance? Yes No (e.g. BUPA, PPP, AXA, etc) If Yes, at what level? page 2 of 6 UP333a MSG 05/2013

3 Section 2 - Occupation Details (to be completed by the employee s HR Coverage Officer) 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 HR Coverage Officer, if possible. 1. Details of Employment Name of employer, place of work & postcode Morgan Stanley 55 Douglas Street Cadogan Square Glasgow, G2 7NP Telephone number Type of industry What is the employee s job title? 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. OFFICE What machines, tools or special equipment (if any) does the employee operate? PC 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 page 3 of 6 UP333a MSG 05/2013

4 Section 2 - Occupation Details continued 3. Physical requirements of job Please tick box applicable to those patterns of work which most closely apply to the daily activities of this employee. Please feel free to annotate or modify these patterns in the interest of accuracy. Physical Demand Characteristics: Work Pattern (Lifting/Carrying) Seldom (less than 15% Occasional (16%-33% Frequent (34%-66% Constant (more than 67% Sedentary 3 5kg (10 lbs) 5kg (10 lbs) Light Medium Heavy Very Heavy Percentage of day spent: 10kg (20 lbs) 10kg (20 lbs) 5kg (10 lbs) push/pull of arm/ leg controls while standing push/pull of arm/ leg controls while standing 25kg (50 lbs) 25kg (50 lbs) 10kg (20 lbs) 5kg (10 lbs) 50kg (100 lbs) 50kg (100 lbs) 25kg (50 lbs) 10kg (20 lbs) over 50kg (100 lbs) over 50kg (100 lbs) over 25kg (50 lbs) over 10kg (20 lbs) Please attach additional sheets if necessary Driving (excluding travel to and from work) Please specify type of vehicle 10% 20% 30% 30-50% over 50% Prolonged periods in one posture 3 Please specify posture Sitting Walking 3 Bending / Stooping 3 Crawling / Kneeling Climbing stairs Climbing ladders or similar Reaching / Stretching 3 page 4 of 6 UP333a MSG 05/2013

5 Section 2 - 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 37.5 hours 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 3 - Payment Details Name and address of the employer s bank to which benefit payments should be made if the claim is admitted Bank Name Bank Address & Postcode Barclays 1 Churchill Place London, E14 5HP Name of Company Account Bank Sort Code Bank or Building Society Account No. Morgan Stanley page 5 of 6 UP333a MSG 05/2013

6 Section 4 - Declarations Check List Please remember to include the following items with this form: 1. Job Description 2. Absence Records 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 2013 Registered office: Milton Court, Dorking, Surrey RH4 3LZ TEL FAX page 6 of 6 UP333a MSG 05/2013