Health questionnaire for the insured TAF life insurances

Transcription

1 You are applying for life insurance. With your application goes a declaration of your health. You can fill out your declaration in this health questionnaire. When your application comprises of two insured persons, each insured has to fill out a separate health questionnaire. The medical consultant will adjudge your answers and advises us about the acceptance of your policy. You can find more information on the medical assessment of your application on This health questionnaire applies to the TAF Personal Overlijdensrisicoverzekering, TAF Special Overlijdensrisicoverzekering, TAF Personal Nabestaandenverzekering and TAF Alimentatiepolis. You can find a further explanation on the purpose and use of the health questionnaire in the Toelichting gezondheidsverklaring levensverzekering on Please read this explanation before you fill out the questionnaire.

2 You are applying for life insurance With your application goes a declaration of your health. Please fill out this health questionnaire completely. The medical consultant will adjudge your answers and advises us about the acceptance of your policy. You can find more information on the medical assessment of your application in the Medische beoordeling bij acceptatie levensverzekeringen on Entitlement to first cognizance You are entitled to be informed first on the medical advice by the medical consultant. This means that the medical consultant cannot inform us or the insurer before he has informed you. If you want to use your right to first cognizance, please send a written request to the medical consultant. Toelichting Gezondheidsverklaring Levensverzekering You can find a further explanation on the purpose and use of the health questionnaire in the Toelichting gezondheidsverklaring levensverzekering on Please read this explanation before you fill out the questionnaire. Fill out all questions correctly and completely It is extremely important that you answer all questions correctly and completely. Failure to fill out this health questionnaire correctly and completely shall be treated as concealment. This may invalidate the insurance and result in TAF rejecting a request for premium waiver or refusing to pay out death benefit. State all your health issues. Even if you think they might not be that important or if you haven t consulted a physician. When you answer a health question positively If you answer a health question with Yes, you have to give a further explanation about your ailment of illness. Please fill out a separate page for each stated ailment or illness. If you need more space than is provided on this form, please continue on a separate sheet of paper. In this case, clearly indicate which question the answers refer to. Note that with question 3 you are required to give an explanation on the enclosed appendix. Changes in your health If the condition of your health changes after completing this questionnaire but before the insurance takes effect, you must inform TAF immediately. Final acceptance is stated by: - your receiving of a confirmation of cover; - your receiving of your policy statement. 2

3 Details intermediary Intermediary number: Name: Address: Zip code/city: Telephone number: 3

4 General details of the insured First name(s): Surname prefix: Surname: Date of birth: Gender: q Male q Female BSN/Social Security Number: l l l l l l l l l l Occupation: Address: Zip code/city: l l l l l l l l 4

5 Risk assessment for the insured How many working hours do you normally put in per week? hours The activities consist of? - Manual labour: hours - Administration: hours - Managing/supervising: hours - Travelling: hours - Otherwise: hours Name of your GP Address: Zip code/city: l l l l l l l l Do you engage in any risky sports or activities (i.e. auto- or motorsport, diving, mountaineering/climbing and/or parachuting, paragliding or sport flying)? What activity? How many times a year? Have you, except for regular holidays, travelled or lived abroad (outside The Netherlands)? Which countries? When? How long? Purpose: Are you planning to, except for regular holidays, travel or live abroad (outside The Netherlands)? Which countries? When? How long? Purpose: Do you drink alcoholic drinks? Amount of glasses of beer (250 ml glass) per week: Amount of glasses of wine (100 ml glass) per week: Amount of glasses of liquor (35 ml glass) per week: Where you ever advised to limit you alcohol consumption? When? By whom? Why? Do you smoke or have you smoked (or used tobacco products) in the past 24 months? What do/did you smoke? How many do/did you smoke per day? Do you still smoke? When did you stop? 5

6 Continuation of risk assessment for the insured Do you use or have you used drugs? What drugs? Do you still use drugs? When did you stop using? Have you ever been declined or accepted under non-standard conditions for a life insurance? Why? When? Which insurer: : Health questions for the insured 1. First name(s): Surname: 2. What is your height and weight? cm kg 3. Do you suffer or have you suffered from any of the following disorders, diseases and/or disabilities (this includes complaints)?* A. Diseases of the brain or nerves such as a stroke, seizures, muscular disease, headaches, dizziness * B. Disorders or complaints of a mental nature such as depression, nervous breakdown, overworked, insomnia, burnout * C. High blood pressure, tightness or pain in the chest, heart palpitations, cardiovascular disease * D. Increased cholesterol, diabetes, gout, thyroid gland abnormalities, metabolic disorders, hormonal abnormalities * E. Lung or bronchial disorders, asthma, shortness of breath, hyperventilation, pleurisy, bronchitis, chronic coughing, allergy, * F. Disorders of oesophagus, stomach, bowels, liver, gall bladder, pancreas * G. Disorders of kidneys, bladder, urinary tracts, sexual organs * H. Benign or malignant lump or tumour, malignant diseases, blood disease, anaemia, HIV, aids * I. Disorders of muscles, limbs or joints (including knee, neck, shoulders), pelvic instability, rheumatism (acute or chronic), polio, paralysis, hunched back, back complaints, back pain, lumbago, hernia, sciatica, RS. * J. Skin disorders, varicose veins, crural ulcer, fistula, thrombosis, embolism * K. Nasal disorders, sinusitis, throat ailments, larynx or vocal chord disorders * L. Diseases, disorders and/or disabilities (including any complaints) not falling within the above categories * * Have you crossed yes at one or more of the categories above: For each disorder, disease or disability, fill in the questions on the appendix to question 3 for a further explanation of your complaints. 6

7 Appendix 1 to question 3 of the health questionnaire At which category in question 3 did you tick yes? Please name the corresponding letter: What disorder, disease or disability (including complaints) are you suffering from or/have you suffered from? During what period(s) are you suffering/did you suffer from this? from until A. GP Did you consult your GP about this in the past 3 years? When did you visit your GP? Are you still under observation? Do you still have health complaints? B. Physician or health professional Have you consulted any of the following physicians or health professionals (e.g. medical specialist, physiotherapist, manual therapist, health centre worker, psychologist, psychotherapist practitioners of alternative medicine such as homeopathy or acupuncture)? What was his/her name? What is his/her specialty? When did you visit him/her? Are you still under observation? Do you still have health complaints? C. Medicine Did any of your physicians prescribe medicine for this? What medicine was prescribed? What is the name of the prescriber? Do you still use this medicine? q Yes, in what dosage: q No, when did you stop using them: D. Hospitalisation Are you/have you been admitted for this to a hospital, sanatorium, psychiatric institution or other nursing institution? When were you admitted? To what hospital? What physician treated you? (name and specialty) Have you had surgery? When was your surgery? In what hospital? What physician treated you? (name and specialty) E. Permanent consequences of an accident Is the disorder, disease or disability (including complaints) the consequence of an accident? q No When did this accident happen? What were the medical consequences? q Yes 7

8 Appendix 2 to question 3 of the health questionnaire At which category in question 3 did you tick yes? Please name the corresponding letter: What disorder, disease or disability (including complaints) are you suffering from or/have you suffered from? During what period(s) are you suffering/did you suffer from this? from until A. GP Did you consult your GP about this in the past 3 years? When did you visit your GP? Are you still under observation? Do you still have health complaints? B. Physician or health professional Have you consulted any of the following physicians or health professionals (e.g. medical specialist, physiotherapist, manual therapist, health centre worker, psychologist, psychotherapist practitioners of alternative medicine such as homeopathy or acupuncture)? What was his/her name? What is his/her specialty? When did you visit him/her? Are you still under observation? Do you still have health complaints? C. Medicine Did any of your physicians prescribe medicine for this? What medicine was prescribed? What is the name of the prescriber? Do you still use this medicine? q Yes, in what dosage: q No, when did you stop using them: D. Hospitalisation Are you/have you been admitted for this to a hospital, sanatorium, psychiatric institution or other nursing institution? When were you admitted? To what hospital? What physician treated you? (name and specialty) Have you had surgery? When was your surgery? In what hospital? What physician treated you? (name and specialty) E. Permanent consequences of an accident Is the disorder, disease or disability (including complaints) the consequence of an accident? q No When did this accident happen? What were the medical consequences? q Yes 8

9 Final statement and signing I request that the application for the insurance be assessed. By signing this application form I confirm that: a) All the questions in the form have been answered completely and truthfully. b) I am aware of the fact that, should the information issued be inaccurate and/or incomplete, the insurer is entitled to cancel the insurance with immediate effect and/or, in accordance with article 7:930 of the Civil Code, refuse payment of benefits. c) I am aware of the fact that the insurance will only take effect once the insurer has assessed and accepted the application. d) I am aware of the fact that the premium may differ, based on my health situation, amended laws and regulations, or if the commencement date of the insurance during the assessment of this application, for whatever reason, will be later than stated in the application. e) I am aware of the fact that I will have to notify the insurance company if my health changes during the period in between filling in the health questionnaire and final approval of the insurancy company or starting date of the insurance. f) I am familiar with the fact that the insurer operates by Code of Conduct for the processing of personal data by financial institutions. This means that also permission will be given to TAF to share details with other parties and other companies, in case this is necessary in order to assess and accept risks, the entering and implementation of contracts, and also the conclusion of payments. g) I am aware of the fact that I have the right to revoke the application for this insurance. Revoking of the application implies that, pursuant to the regulations of the Dutch Authority for the Financial Markets, I can use the opportunity to return the policy to TAF B.V. without justification, within one month after the date of issue of the first policy document. h) I have received and read the policy conditions, and understood and accepted them. The applicable policy conditions are available on i) I am aware of the terms in this application form and the fact that I accept the terms as part of the contractual agreement. j) I have read the explanation of the health questionnaire. The explanation is part of this form and can be found on Place: Signature of the insured: Date: TAF BV, Postbus 4562, 5601 EN Eindhoven 9 TAF-GVK-ENG-ORV a