GROUP INCOME PROTECTION

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1 GROUP INCOME PROTECTION PROACTIVE PROTECTION PROVIDED BY METLIFE POLICY PROPOSAL FORM This policy is provided and underwritten by MetLife Europe Limited, which trades as MetLife. This form must be completed by the policyholder. Please print clearly, sign, date and return the proposal form to your financial intermediary. The form must be returned to MetLife by the financial intermediary within 30 days of MetLife assuming risk. Please read this warning carefully. If you have any questions or require help in completing the form please contact your Financial Intermediary. The application will be set up based on the information you give us. You must disclose all facts that are material to the insurance and provide true, accurate and complete information. Material facts are facts which would influence us in our decision on the terms and conditions (if any) of the insurance cover we offer you and are not restricted to the answers to the questions below. If you are uncertain as to whether a fact is material, you should disclose the full details to us. Before the policy commences, you must immediately report to us any change from the answers in this form or to any other information you have provided. The information you provide will form the basis of the contract of insurance between you and us. If you provide misleading information or you fail to disclose material facts before the insurance cover commences, the insurance cover provided under the policy may be void and it may result in a claim for benefit being rejected or any benefit payable being reduced.

2 2 1. APPLICANT S DETAILS Please complete in block capitals Employer name Registered address Main employer contact details Postcode Name Correspondence address Postcode Telephone number Trading address Postcode Company registration number (if applicable) Scheme name (Leave blank if same as employer) Type of organisation (e.g. limited company, partnership, charity etc) Name of any subsidiary(ies) or associated company(ies) to be held under this scheme (if applicable) Nature of trade or business carried out by the employer (please describe the activities of the company) Nature of the occupations of current members Total workforce (number of insured members plus number of non-insured employees and /or partners)

3 3 2. EXISTING SCHEME DETAILS This section must be completed even if there is no existing scheme Please tick one of the following statements as appropriate: The Scheme is currently insured or self-insured on an identical basis please answer all questions. The Scheme is currently insured or self-insured on a non-identical basis please answer all questions. There is no existing scheme please answer question f. a. Current insurer b. Free cover limit c. Scheme history for the last 5 years (please complete table below) Insurer Time Period from/to Number of lives Total insured benefit / salary d. Individual claims history for the last 5 years Please provide the following details in respect of all claims submitted during the previous 5 years. This should include all current, terminated, pending, settled and declined claims. Continue on a separate sheet if necessary. Gender Date of Birth Current benefit amount Reason for incapacity Start date Cease date Settlement amount

4 4 e. Have any members, eligible employees and / or eligible partners previously been declined cover, had cover postponed, had cover restricted to a certain benefit level, had an exclusion applied or for whom an additional premium has been required following medical underwriting; and are there any members, eligible employees and / or eligible partners currently being medically underwritten? Yes No (If Yes please complete table below) Name Gender Date of birth Scheme salary Previous scheme benefits Previous free cover limit Previous insurer s terms Benefit to which terms apply Date of underwriting decision Forward underwriting bar Subject to any temporary cover provided during the underwriting process, please note that any member / eligible employee / eligible partner listed above will not be granted cover under the policy until satisfactory evidence of health is received and the risks are accepted by MetLife. f. Are any members / eligible employees / eligible partners based Yes No (If Yes please complete table below) overseas or do any members / eligible employees / eligible partners travel overseas for business purposes? Name Occupation Country Frequency & duration of visits

5 5 3. BASIS OF BENEFITS Please select the benefit basis required. Category name Basic income benefit (employees & partners) Category 1 Category 2 Category 3 as a percentage of insured earnings (up to a maximum of 80%) less benefit offset (if applicable) Optional pension scheme contributions benefit (employees only) Employer s pension scheme contributions benefit (if applicable and up to a maximum of 35%) Employee s pension scheme contributions benefit (if applicable and up to a maximum of 5%) THERE IS AN OVERALL MAXIMUM FOR PENSION SCHEME CONTRIBUTIONS BENEFIT (EMPLOYER S AND EMPLOYEE S) OF 35% or 75,000 p.a. IF LESS. Optional national insurance contributions benefit (employees only) (if applicable) Deferred period (13 or 26 weeks) Benefit payment period (1, 2, 3, 4 or 5 years; or to termination age) Escalation rate (if applicable) Definition of Earnings Definition of pensionable earnings (if this differs to Earnings ) Definition of Incapacity For each membership category select one of the following Incapacity definitions: 1. Unable to perform their own occupation; 2. Unable to perform their own or another suitable occupation; or 3. Unable to perform their own occupation switching to unable to perform their own or another suitable occupation after 2 years of incapacity.

6 6 4. ELIGIBILITY Category 1 Category 2 Category 3 Minimum entry age (age attained) Maximum entry age (at next birthday) Termination age (age attained) Exact eligibility conditions (including service qualification period). Please confirm exact eligibility conditions to the pension scheme, if applicable. When can eligible employees / eligible partners enter the scheme? The scheme is to be Compulsory Linked to the pension scheme membership Take up rate of employees eligible to join the pension scheme

7 7 5. MEMBERSHIP DATA For policies of 20 or more members Please give totals as at the commencement date. If the figures differ from the last quotation MetLife issued in respect of the scheme to be insured, please attach a revised membership list. A revised quotation may be issued to you. Number of members Total salary roll Are these figures different to what was listed in the latest quotation we have issued to you? Yes No For policies of fewer than 20 members Has the membership data changed since the quotation was last issued? Yes No If yes, please complete the table below or supply the membership data separately. Name Gender Date of birth Annual salary & benefit Occupation Membership category Location members, please complete section above

8 8 6. ACTIVELY AT WORK DECLARATION This refers to this policy proposal This Actively at Work Declaration must be completed for a scheme which is: a new scheme or a scheme switching on a non-identical basis; and has fewer than 20 eligible employees and / or eligible partners. Did any eligible employees and / or eligible partners not satisfy the actively at work definition due to sickness or accident: on the last working day before the commencement date; and for 10 or more working days in the previous 60 days before the commencement date? Yes No If Yes, please provide details: Name Cause Dates of absence from / to Benefit Important information Any eligible employee and / or eligible partner listed above will not be granted cover until satisfactory evidence of health is received and they are accepted by MetLife. If the above Declaration does not have to be completed, please refer to the policy technical guide in respect of the Actively at Work requirements that will apply. Actively at work means, in relation to an employee employed by the employer or a partner of the employer at any relevant date, that they have not received medical advice to refrain from and are actively engaged in or are otherwise following their normal occupation on that date. Actively means the employee or partner is, in the opinion of the insurer, mentally and physically capable of working their normal contracted number of hours, either at their usual place of business or at the location to which business requires them to travel. Absence from work does not include holidays, maternity, paternity and adoption leave, or any other authorised leave to be approved by the insurer.

9 9 7. START OF COVER & DECLARATION We hereby request that MetLife assume cover for the above named Group Income Protection Scheme in accordance with the standard policy terms & conditions provided with: Quotation No. Dated D D M M Y Y Y Y We understand that the above quotation is subject to the information supplied by us in response to MetLife s underwriting questions. We understand that if any material facts supplied by us in this proposal form affect the premium rate detailed in the quotation above, a new quotation will be issued. We also understand that MetLife will not assume risk, until we have received written confirmation that their underwriting criteria have been satisfied. Commencement date and payment frequency Requested D D M M Y Y Y Y Requested review date D D M M Y Y Y Y commencement date (assumed one year after the commencement date unless stated) MetLife will confirm in writing the date cover has started. This date cannot be backdated. Frequency with which premiums will be paid Annual Bi-annually Quarterly Monthly Declaration We declare that we have disclosed all facts material to the insurance cover and that the answers to the questions or to MetLife s underwriting questions in this form are true, accurate and complete. We agree that the application, together with statements made and information supplied by us in connection with the application, shall form the basis of the policy cover(s) granted by MetLife. We have read the data protection and confidentiality notice below and we note and understand the purposes for which personal data and sensitive personal data will be stored and processed by MetLife and with whom the data may be shared or transferred. We warrant that personal data provided to MetLife for the purposes of the Policy is provided in accordance with the rights of the data subject under the Data Protection Act We consent to MetLife seeking information from any insurance company to which a proposal for Group Income Protection cover has been made and we authorise the giving of such information. We understand that we must notify MetLife of any change in the answers to the above questions and information supplied before the insurance cover commences. We acknowledge and understand that it is not MetLife s responsibility to advise on and confirm the way in which any particular scheme operates, or with regards to the tax treatment of a scheme. We declare that details for the inclusion of all future members of the scheme will be notified to MetLife no later than the review date following those members satisfying the eligibility conditions. We agree to furnish such medical evidence and confirmation of age satisfactory to MetLife as may be requested from time to time. Signature Position Name For and on behalf of Date D D M M Y Y Y Y

10 10 8. AUTHORISED SIGNATORIES Please provide a minimum of 2 authorised persons for completion of policy documentation (in the event one is on leave, out of the office etc.). Signature Position Name Date D D M M Y Y Y Y Signature Position Name Date D D M M Y Y Y Y Signature Position Name Date D D M M Y Y Y Y Signature Position Name Date D D M M Y Y Y Y

11 11 DATA PROTECTION & CONFIDENTIALITY NOTICE Member information, or members personal data or sensitive personal data (for example their medical notes and records) as defined by the Data Protection Act 1998, whether included in this application or otherwise, is private and confidential. We comply with all legislation relating to Data Protection. We hold or process personal data or sensitive personal data for the purposes set out below. We will store and process data for underwriting and claims, fraud and crime prevention and detection, marketing purposes, to carry out research and analysis, to set up and administer, and provide information about any policy in connection with any reinsurance and in connection with any subsequent application(s). We may share with or transfer members data for the above purposes to our parent company and other companies within the company group, to our successors or assigns, to other insurers, to insurance intermediaries, to our service providers, to our reinsurers or to third party companies to process or manage information on our behalf. These companies may operate outside the European Economic Area. Data will be processed as securely as if we were processing it, under a strict code of privacy and security. We may process or share personal data or sensitive personal data with other insurers, reinsurers, law enforcement agencies and other third parties for the purposes of fraud and crime prevention and detection and to comply with our statutory obligations.

12 Want to find out more? Talk to your IFA or EBC or call us on Products and services are offered by MetLife Europe Limited which is an affiliate of MetLife, Inc. and operates under the MetLife brand. MetLife Europe Limited (trading as MetLife) is authorised by the Central Bank of Ireland and subject to limited regulation by the Financial Conduct Authority. Details about the extent of our regulation by the Financial Conduct Authority are available from us on request. Registered address: 20 on Hatch, Lower Hatch Street, Dublin 2, Ireland. Registration number UK branch address: One Canada Square, Canary Wharf, London E14 5AA. Branch registration number BR M COMP90140ML OCT 2013

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