DISCOUNTED GIFT & INCOME TRUST UNDERWRITING/HEALTH QUESTIONNAIRE

Transcription

1 DISCOUNTED GIFT & INCOME TRUST UNDERWRITING/HEALTH QUESTIONNAIRE

2 1. TYPE OF UNDERWRITING REQUIRED Please tick one box only A. Full advance underwriting required (you must now complete this form) If the full advance underwriting option is taken, the Bond application will not be processed until the underwriting process is complete and a certified discount letter has been issued to you and you have indicated your willingness to proceed. Flexible Discounted Gift & Income Trust Full advance underwriting must be used if the value of your investment exceeds your available inheritance tax nil rate band threshold (for more information contact your financial adviser). B. Full concurrent underwriting required (you must now complete this form) If the full concurrent underwriting option is taken, the Bond application and your investment will be processed normally, without waiting for an underwriting decision to be made. This will ensure no delay in investing your money, but will also mean that you will not know the amount of the discount (if any) until after the gift is made. You should also note that a certified discount letter can be issued only if the report obtained from your own doctor provides sufficient evidence of your state of health as at the date of the gift. This option should not be selected if your doctor does not have up to date information on your state of health. Flexible Discounted Gift & Income Trust Full concurrent underwriting should be used only where the value of your investment is within your available inheritance tax nil rate band threshold (for more information contact your financial adviser). C. No underwriting required In this case, you will not need to complete this form and we will not issue a certified discount value. Flexible Discounted Gift & Income Trust No underwriting should only be used where your gift is within your available inheritance tax nil rate band threshold (for more information please contact your financial adviser). 2. HEALTH QUESTIONNAIRE FIRST APPLICANT Name Address Postcode Date of birth (DD MM YYYY) Amount of gift Income requirement Commencing on (DD MM YYYY) (whole pounds only) and monthly/quarterly/half-year/annually thereafter* *please delete as appropriate. The maximum withdrawal is 7.5% pa of the amount invested. The income details provided above should correspond with the details inserted or to be inserted in boxes E and F of the Discounted Gift & Income Trust form. This questionnaire must be completed in all cases where full underwriting is required. Please make sure you understand and answer every question in this form honestly and in full. FIRST APPLICANT A. Please state your height Height (without shoes) Height (without shoes) without shoes and weight in normal indoor clothes. Weight (in normal clothes) Weight (in normal clothes) 1

3 2. HEALTH QUESTIONNAIRE (CONTINUED) FIRST APPLICANT A. Have you used tobacco or nicotine replacement products in the last 12 months (tobacco products include cigarettes, cigars, pipes or nicotine replacements)? Yes No Yes No B. If you smoke cigarettes, how many on average do you smoke each day? cigarettes each day cigarettes each day C. Do you regularly drink Yes No Yes No in excess of 35 units of Beer: 1 pint = 2.5 units; Beer: 1 pint = 2.5 units; alcohol per week? Wine: 1 glass (175ml) = 2.5 units; Wine: 1 glass (175ml) = 2.5 units; If Yes, please give details of how much Spirits: 1 standard measure (35ml) = 1.5 units). Spirits: 1 standard measure (35ml) = 1.5 units). alcohol you drink Beer pints per week Beer pints per week each week. Wine glasses per week Wine glasses per week Spirits standard measures per week Spirits standard measures per week D. Have you attended or been advised to attend your doctor s surgery, any hospital or clinic for any form of advice, operation, treatment or test within the last 12 months? Yes No Yes No E. Are you subject to regular reviews or receiving any medical treatment or attention? (colds, influenza, minor injury and routine pregnancy consultations may be excluded) Yes No Yes No F. i. Have you ever had a positive test for HIV or Hepatitis B or C? Yes No Yes No ii. Within the last five years have you tested positive or been treated for any disease which was transmitted sexually? Yes No Yes No iii. In the last five years have you used recreational drugs such as cocaine, heroin or cannabis? Yes No Yes No If you have answered Yes to any of the above, please provide full details. (For confidentiality these may be sent direct to our Chief Medical Officer.) 2

4 2. HEALTH QUESTIONNAIRE (CONTINUED) FIRST APPLICANT G. Is any mental or physical illness or injury disabling you now, or has it done so for any period of two weeks or more during the last five years? Yes No Yes No H. Have you ever suffered from heart disease, stroke, cancer, diabetes, kidney disease, multiple sclerosis or any other disabling condition? Yes No Yes No If you have answered Yes to any one or more of questions D-H inclusive, please provide full details below. I. Please give the name and address of your current doctor. Name Dr Address Please continue on a separate sheet if necessary. Postcode Telephone number If you have changed your doctor within the last six months, please give details of your previous doctor. Name Dr Address Postcode Telephone number 3

5 3. DECLARATION I/We declare that I/we have read and understood the Important notes set out overleaf and that all statements made by me/us in this application are true and complete to the best of my/our knowledge and belief. I/We consent to Scottish Widows seeking information from any doctor who at any time has attended me/us concerning anything which affects my/our physical or mental health, or seeking information from any insurance office to which an application has been made for assurance on my/our life/lives and I/we authorise the giving of such information. I/We have had written notice of my/our statutory rights under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991, and I (first applicant) do not* wish to see any report before it is sent. I (second applicant) do not* wish to see any report before it is sent. I/We understand that I/we shall retain the right to see, within the next six months, any report produced. I/We agree that a copy of this consent shall have the validity of the original. I/We further consent to Scottish Widows obtaining a medical report after my/our death(s) from any Medical Practitioner who has at any time attended me/us. Such consent shall endure for an indefinite period following my/our deaths. I/We have read any answers completed other than in my/our handwriting and confirm that they are correct. *If you wish to see your medical report delete not ; this is likely, however, to delay the processing of your application. DATA PROTECTION ACT Your information will be held by Scottish Widows which is part of the Lloyds Banking Group. More information on the Lloyds Banking Group can be found at We will share your personal information from your application with fraud prevention agencies. If false or inaccurate information is provided and fraud is identified, details of this fraud will be passed to these agencies to prevent fraud and money laundering. Further details explaining how information held by the fraud prevention agencies may be used can be obtained by reading the privacy notice at or contacting your local branch. We may ask you to provide physical forms of identity verification when you open your account. Alternatively, we may search credit reference agency files in assessing your application. The agency also gives us other details and information from the Electoral Register to verify your identity. The agency keeps a record of our search, whether or not your application proceeds. Our search is not seen or used by lenders to assess your ability to obtain credit. If you apply to us for insurance, we will pass your details to the insurer and their agents. If you make a claim, any information you give to us, or to the insurer, may be put onto a register of claims and shared with other insurers to prevent fraudulent claims. Your personal information will be shared within the Lloyds Banking Group so that we and any other companies in our Group can look after your relationship with us. By sharing this information it enables us to better understand your needs and provide products in the efficient way that you expect. Under the Data Protection Act you have the right of access to your personal data. The Act allows us to charge a fee of 10 for this service. If anything is inaccurate or incorrect, please let us know and we will correct it. Any information which you have provided relating to your health or lifestyle is required for underwriting purposes and is defined as sensitive data by the Data Protection Act This information will be held securely with access limited to those who need to see it. It is important that you understand how the personal information you give us will be used. Therefore, we strongly advise that you read our Privacy Statement, which you can find at or you can ask us for a copy. By signing this application/ declaration you agree to your personal information being used in the ways we describe in our Privacy Statement. Please let us know if you have any questions about the use of your personal information. We may administer the investment or policy and any existing investments or policies you may have with Scottish Widows, and provide other services, from centres in countries outside the European Economic Area (such as India and the USA) that do not always have the same standard of data protection laws as the UK. However, there will be a contract in place to ensure that your information is adequately protected, and we will remain bound by our obligations under the Data Protection Act even when your personal information is processed outside the European Economic Area. We may record and monitor telephone calls with you in case we need to check we have carried out your instructions correctly and to help improve our quality of service. Lloyds Banking Group companies may use your information to contact you by mail, telephone, or text message about products and services that may be of interest to you. If you do not wish to receive this information please tick this box. Please note: Although we reserve the right to seek information on health matters from your doctor, we may not necessarily do so and you are therefore advised most strongly to consider carefully the questions asked as we will be relying on your answers in considering the application. 4

6 FIRST APPLICANT Signature Date (DD MM YYYY) Full name (in CAPITAL LETTERS) Signature Date (DD MM YYYY) Full name (in CAPITAL LETTERS) NOTICE OF YOUR STATUTORY RIGHTS UNDER THE ACCESS TO MEDICAL REPORTS ACT 1988 OR THE ACCESS TO PERSONAL FILES AND MEDICAL REPORTS (NORTHERN IRELAND) ORDER 1991 It may be necessary for us to obtain medical reports to support your application. Before we can ask any doctor that you have consulted to complete a report, we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order Your rights under these Acts are as follows: 1. You do not have to give your consent, but if you do not we may be unable to proceed. This does not stop you from applying to other companies for insurance. 2. You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to retain the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us. 3. If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. A duplicate report can be sent to your doctor on request should you wish to see it at a later date. 4. If you consider any aspect of the report to be incorrect or misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him/her to attach a statement outlining your views, which will then accompany the report. 5. Your doctor can withhold access to the report if he/she feels that it would cause physical or mental harm to you or others. 6. Your medical report will contain details of relevant consultations, treatment, operations, investigations and test results that you have undergone at any surgery, hospital or clinic. Your consent will give us the right to access to this information. 7. If you have any questions regarding your rights under the Acts or any questions relating to the process of obtaining, accessing or storing medical information, please write to our Chief Underwriter. 5

7 IMPORTANT NOTES Your answers to the health questions above will be used to assess the application and you must, therefore, answer them honestly and in full to the best of your knowledge and belief. 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 the application for insurance, taken together with any other insurance policies you already have, totals: 500,000 or less for life assurance 300,000 or less for critical illness, or paying annual benefits of 30,000 for income protection insurance (the financial limits ). Above these limits, you may need to tell us about certain genetic test results when applying for insurance. We will only be interested in genetic test results where the Government s Genetics and Insurance Committee (GAIC) has approved them for insurers to use. If you think this may apply to you, please ask us for details of the current position. These details are also available from the ABI website at: 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. Insurers pass information on claims concerning income protection insurance, critical illness insurance and waiver of premium benefits to the Income Protection Claims Register, run by the Association of British Insurers (ABI). The aim is to prevent duplicate fraudulent claims. When you make a claim, we will notify the register of the event. You can ask us for more information about this. TO BE COMPLETED BY THE FINANCIAL ADVISER Financial adviser details FCA reference or principal firm (if applicable) Name of principal firm (if applicable) Name of adviser/registered individual Network member firm name/appointed representative firm name (if applicable) Staff ID (if applicable) Address Postcode Telephone number Fax number We will assume that this application is being submitted on a Whole of Market basis, unless you advise us otherwise by ticking one of the following: Multi-tie Tied Non-intermediated 6

8 Scottish Widows Limited. Registered in England and Wales No Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number /15