Group Income Protection Insurance Claim form to be completed by the Employee

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1 Group Income Protection Insurance Claim form to be completed by the Employee Please complete and return this claim form in the pre-paid envelope provided as soon as is possible. Please answer all questions in full. Failure to provide full information as requested may delay claim consideration. SECTION 1 Personal details. Full Name: (Mr/Mrs/Miss/Ms) Date of Birth: Marital Status: Address: (including postcode) Telephone Number: (including code) SECTION 2 Occupational details. Please confirm the name and business address of your employer. What was your precise occupation immediately prior to disablement? Please provide a copy of your job description; if this is not available, please describe your normal duties in detail. How many staff are under your control: Page 1 of 8

2 SECTION 2 Occupational details (continued) Please detail any environmental conditions that you think aggravated your disability (for example dust, weather, work-place temperature extremes, etc) Does your normal occupation involve any manual work, physical work or travel (other than to and from work)? If it does, please provide full details, including the proportion of time spent on these duties. How many hours do you work in a typical week? When do you expect to return to work (please answer all relevant options) On a full-time basis? On a part-time basis? In your previous occupation? In a different occupation? (please give full details) Will this different occupation be on a full-time or part-time basis? If part-time, what hours will you be working? Please detail any other employment that you have had in the last 5 years if none, please say so. Dates Job Title Brief description of duties Name of employer (if self-employed, please say so) Page 2 of 8

3 SECTION 3 Nature of disability. What are you (or have you been) suffering from? Please describe your current symptoms in detail. Was your disability due to an accident? Yes No If it was, please provide full details including date, time, place, and whether you suffered any visible wounds or bruising. From what date were you totally disabled? When was your last working day? What date did you first seek medical advice for this? Page 3 of 8

4 SECTION 3 Nature of Disability (continued). Have you suffered from this, or a similar disability, before? Yes No If you have, please provide full details including dates, and whom you consulted. Please give the name and address of any Doctor(s) consulted in connection with this incapacity. Please give the name and address of your usual GP if different to above. If you have been a hospital in-patient, please provide: (a) The full name, postal address, and telephone number of the hospital attended, along with your patient reference number if known. (b) The dates of admission and discharge (please provide copies of any associated certificates) Page 4 of 8

5 What treatment have you received in connection with your disability? What current treatment are you receiving? Do you have any future referrals to any medical specialists, or are you awaiting details of such referrals? Yes No If yes, please provide relevant full names, postal addresses, and telephone numbers and confirm the dates of such referrals. What parts of your job are you (or were you) unable to do? Are you still unable to do these parts? Yes ; No If you are able, please state date of recovery: Have you done any work at all, either paid or unpaid, since the date you were first totally disabled? Yes ; No If you haven t, when do you think you will be able to carry out some of your work? Page 5 of 8

6 SECTION 4 Income prior to Disability. Income from Employment Please confirm your gross earned income, as declared for tax purposes, for the 12-month period prior to your disability. Please enclose your latest P60 (or SC60 for sub-contractors). Income from State Benefits Please confirm what State Benefits you have received, or are entitled to receive, from the end of the deferred period. Benefit Title Weekly amount received ( ) Please enclose a copy of your benefit entitlement letter issued by the DSS if applicable (form BS12, BS49, or BS50). Other Insurances Are you insured against sickness and/or accident through any other policies? Yes ; No If you are, please provide the following information in respect of each policy. Insurer Policy Deferred Period Policy Commencement Benefit Level Number (weeks) Date Are you currently claiming, or intending to claim, benefits from these policies? Yes ; No Page 6 of 8

7 SECTION 4 Income prior to Disability (continued) Other Income Are you likely to be receiving any other income from any source (other than this policy) whilst you remain disabled? (You should include continuing salary, pensions, commissions etc.) If you have, please provide full details. Yes ; No Is there any other information not requested on this form that you think will be of assistance to your claim consideration? NOW PLEASE CHECK ALL YOUR ENTRIES ON THIS FORM AND ENSURE THAT NO DETAILS HAVE BEEN OMITTED ANY SUCH OMISSIONS WILL DELAY ANY MONEY DUE TO YOU. Page 7 of 8

8 CONSENT FOR MEDICAL IN FORMATION Rights Under the Access to Medical Reports Act 1988 Before applying for medical information from a doctor who has cared for you, we need your consent. Before doing so, however, you should read this notice carefully, as it sets out your rights under the Access to Medical Reports Act 1988 and the procedures for dealing with medical reports. You do not have to give your consent, but if you do, you can say whether you wish to see the report before it is sent to Omnilife. If you do not give your consent, we will be unable to proceed with your claim appliction. If you say you wish to see the report, we will tell you when we will be writing to your doctor, and we will tell him you wish to see the report. You will then have 21 days to contact the doctor about arrangements for you to see the report. The quicker you act, the quicker your claim can be considered. If you do not wish to see the report, we do not have to notify you when we apply for one. If, however, before such a report is sent to us, you write to the doctor saying you wish to see it, you will have 21 days to contact the doctor about arrangements for you to see the report. Whether or not you say you wish to see the report before it is sent to us, the doctor must let you see a copy for up to six months after it is supplied, if you ask. If you ask the doctor for a copy of the report, he can charge you a reasonable fee to cover his costs. Once you have seen a report before it is sent to us, the doctor cannot submit it until he has your consent. You can write to the doctor, asking him to amend any part of the report which you consider to be incorrect or misleading, and have attached to the report a statement of your view on any part where you and the doctor are not in agreement and which the doctor is not prepared to alter. The doctor is not obliged to let you see any part of the report if, in his opinion, it would be likely to cause serious harm to your physical or mental health or that of others, or would indicate the doctor s intention towards you, or if disclosure would be likely to reveal information about, or the identity of, another person who has supplied information about you, unless that person has consented or the information relates to, or has been supplied by, a health professional involved in caring for you. In such cases, the doctor must notify you and you will be limited to seeing any remaining part of the report, if it is the whole report which is affected, he must not send it to us unless you give your consent. Consent For Medical Information Before signing in the space below, you should read carefully your rights under the Access to Medical Reports Act The main points of which are as follows. You can withhold your consent. You can see the report before it is sent to us, or during the six months after that. You can ask the doctor if he will amend any part of the report that you consider to be incorrect or misleading. If the doctor is not in agreement, you may append your comments. The doctor can withheld from you the report, or part of it, if he thinks you would be harmed by seeing if. I do not wish to see the report before it is sent to the Company I do wish to see the report before it is sent to the Company I declare that to the best of my knowledge and belief the information given above is true and complete in every respect and that I have not withheld any material information that may influence the assessment or acceptance of this proposal. I have been informed of my Statutory Rights under the Access to Medical Reports Act, 1988, as explained above, and in connection with the claim currently applied for, hereby, consent to Omnilife seeking medical information from any doctor who at any time has attended me concerning anything which affects my physical or mental health, or seeking information from any Insurance Company to which a proposal has been made for insurance on my life and I authorize of the giving of such information. I agree that a copy of this consent shall have the validity of the original, I agree that this proposal together with any statements made to any medical examiner(s), in respect of this proposal, shall form the basis of the contract between me and Omnilife Insurance Company Limited. Signature Date Page 8 of 8

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