protection Protection Cover Application Form Application No. 1. Insureds Title Surname Title Surname Date of birth (evidence required)

Transcription

1 Protection Cover Application Form Application No. protection 1. Insureds 1st Life to be insured Forename(s) 2nd Life to be insured (if applicable) Forename(s) Title Surname Title Surname Present address Present address Marital Status Daytime telephone number Alternative telephone number address Occupation (describe type of business and nature of duties) Marital Status Daytime telephone number Alternative telephone number address Occupation (describe type of business and nature of duties) Date of birth (evidence required) Date of birth (evidence required) 2. Grantee(s) if different Full name(s) and address(es) of person(s) who are effecting this policy Relationship to Life/Lives to be insured or details of insurable interest 2a. Purpose of cover 3. Your Protection Cover Requirements (For full details on all cover types please consult our Protection Cover brochure). Cover Details Single Life Joint Life Dual Life Joint Life 2nd Death Term Years (not available for Mortgage Protection Policies) (available for Guaranteed Whole of Life only) Monthly Direct Debit Yearly Direct Debit Premium quoted

2 1. Mortgage Cover (Reducing) Please select one of the following covers A Mortgage Protection Life Cover Sum Assured B Mortgage Protection Life Cover with Accelerated Serious Illness If B selected, please select - Hospitalisation Cover Yes No If yes please specify amount (50/100/150) 2. Life and/or Serious Illness Cover (Level) Please select from the following covers 1st Life Sum Assured 2nd Life Sum Assured (if dual life only) A. Life Cover (Level and Convertible Term Assurance) B. Stand Alone Serious Illness Cover* C. Accelerated Serious Illness Cover* If B or C selected, please select - Surgical Cash Hospitalisation Cover If yes, please specify amount (50/100/150) If A, B or C selected, please select - Indeation Yes No Conversion Option Yes No D. Guaranteed Whole of Life Cover 1st Life Sum Assured 2nd Life Sum Assured Guaranteed Increasing Benefit Option Yes No If the policy is to be written in trust please select trust type Sec 72/Sec 60 General Trust * Applicants for Serious Illness Cover should refer to the Standard Restrictions section in their Protection Cover brochure for details of the restrictions, conditions and eclusions that apply to this cover. Hibernian s Requirements, Please complete Parts 1 and 2 Please note carefully Failure to disclose all material facts could render your contract void. Material facts are those, which an insurer would regard as likely to influence the assessment and acceptance of an application for insurance. If you are in any doubt as to whether certain facts are material, such facts should be disclosed. Any changes to the answers given before the cover comes into force must be notified to Hibernian Life & Pensions Limited. In accordance with the Disability Act 2005, you should not disclose the results of any genetic tests undertaken.

3 Part 1 Personal statements to be answered by the lives to be insured (Please answer carefully giving full details) 1st Life to be insured 2nd Life to be insured Name and address of your current Medical Attendant or family Doctor and any other specialist you may have attended. If you have changed your Doctor in the last 18 months, please give the name and address of your previous Doctor. Replies 1st life Replies 2nd life 1 (a) What is your height? ft ins ft ins or mtrs cms mtrs cms (b) What is your weight? st lbs st lbs or kilos kilos 2. Have you smoked any form of tobacco in the past year? If Yes please state consumption and frequency: 1st Life Cigarettes Cigars Pipe Tobacco (ozs) daily weekly 2nd Life Cigarettes Cigars Pipe Tobacco (ozs) daily weekly 3. How much alcohol do you currently drink (units)? weekly weekly Please quantify e.g. 1 short or a glass of wine = 1 unit, 1 pint = 2 units Part 2 Personal statements to be answered by the lives to be insured (If any questions are answered Yes, please give full details and ask your financial adviser for the relevant Medical or Hazardous Pursuits Questionnaire which must be completed and returned with your application form) Replies 1st life Replies 2nd life 1. Have you made a previous application for life, serious illness, income protection or premium protection to Hibernian Life & Pensions? 2. Are you currently proposing or have you proposed in the last 12 months for life, serious illness, income protection or premium protection with any other company? If yes please state which companies and the sum(s) insured proposed. 3. Has a proposal on your life ever been postponed, declined or accepted on special terms? Please provide full details of the companies and dates. 4. (a) Do you engage or intend to engage in any hazardous pursuits or occupations? (e.g. aviation, working at heights, climbing, diving or motor sports etc) (b) Have you in the last 5 years, are you currently or do you intend to in the future, travel, live or work abroad? (Travel to or residency in the following can be ignored: United Kingdom, Portugal, Spain, France, Belgium, Holland, Germany, Switzerland, Austria, Italy, Greece, Denmark, Norway, Sweden, Finland, Cyprus, Malta, Luembourg, North America, Australia and New Zealand). If yes please provide full details.

4 Part 2 Personal statements to be answered by the lives to be insured 5. Have you ever had or been advised to have any medical attention, operations, -rays, tests, investigations or treatment for any of the following: Replies 1st life Replies 2nd life (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) (l) Disease of the heart, circulatory system, heart attack, angina, chest pain, stroke, blood pressure or raised cholesterol? Diabetes? Mole that has changed in size, colour or bled, lump, growth, tumour or cancer? Stomach, bowel complaint, hernia, irritable bowel syndrome, diverticulitis, ulcerative colitis or Crohn s disease? Liver, abnormal liver function or liver function tests? Asthma, bronchitis, sarcoidosis or any other respiratory disorder? Depression, aniety, mental illness or work related stress? Multiple sclerosis, any other neurological disorder, double vision or any other disorder of the eyes (other than the wearing of prescribed glasses or contact lenses)? Numbness, loss of feeling or tingling of the limbs or face, or temporary loss of muscle power? Disease or disorder of the ears or hearing? Epilepsy, seizure or vertigo? Kidney or bladder disorder? (m) Arthritis, rheumatism, joint, muscle or bone disorders, backache, back injury, whiplash or other physical disability? (n) Have you ever had any other illness or injury requiring medical attention, surgical operation or special investigation by a consultant or at a hospital? (Colds, influenza and minor injuries may be ecluded). 6. Are you now or have you recently been prescribed drugs, medication, advised medically to diet or are you currently undergoing any other form of treatment? 7. Have you ever been treated for alcoholic habits, had in-patient treatment for alcohol abuse, been advised medically to reduce your alcohol consumption or cease alcohol completely or taken drugs for other than medical reasons? 8. During the last 5 years have you had any illness or injury requiring medical attention? (Colds, influenza and minor injuries may be ecluded). 9. Have you been tested positive for HIV/AIDS or Hepatitis B or C or have you been tested/treated for other seually transmitted diseases or are you awaiting the result of any such tests? For etra confidentiality, these details can be sent to the Chief Medical Officer at: Hibernian Head Office, One Park Place, Hatch Street, Dublin 2. If Yes, please provide details

5 10. Has any one of your natural parents, brothers or sisters whether living or dead ever suffered from diabetes, stroke, heart or kidney disease, cancer, or any hereditary disease or disorder, (such as Huntington s chorea, polycystic kidney disease) before 60? If Yes, give full details. Replies 1st Life Relation Disease/Disorder (If Cancer, state site) Age at Diagnosis Replies 2nd Life Relation Disease/Disorder (If Cancer, state site) Age at Diagnosis 11. Does the amount of total cover (Life and Serious Illness) that you already hold, including any cover that is currently proposed or contemplated, eceed 15,000,000? Types of cover include, but are not limited to, any personal cover, mortgage cover, (commercial or personal) business cover and death in service cover. If you have answered yes to any of questions 1-11, please give full details, using a separate sheet if necessary.

6 Declarations (must be completed for all Covers) I/We, the life/lives to be insured, declare that I/we am/are in good health and I/we irrevocably authorise and request any doctor or other person who may be in possession of, or hereafter acquire, any information regarding my/our health up to the present time to disclose such information (with the eception of the results of genetic tests) to Hibernian Life & Pensions and I/we agree that this authority shall remain in force after my/our death as well as prior thereto. I/We consent to Hibernian Life & Pensions seeking information from any insurance company to which an application on my/our life/lives or for accident or sickness has been made and I/we authorise the giving of such information (with the eception of the results of genetic tests). I/we declare that the answers to the questions on the application whether in my/our handwriting or written by another at my/our dictation are strictly true and complete and that this application and Declaration together with any statements made by the life/lives to be insured to the Medical Eaminer acting for Hibernian Life & Pensions, or any other insurance company, shall be the basis of the contract and I/we understand that if a premium is tendered or a direct debit order signed no binding contract is created until Hibernian Life & Pensions assumes risk. Hibernian Life & Pensions will keep the information you provide about yourself and about third parties confidential. We may use it to provide and administer financial services products provided by us and sometimes with our affiliates and/or commercial partners. We may pass the information, in confidence, for these purposes to agents or service providers we have appointed, regulatory organisations, other insurance and financial services companies (directly or via a central register), other Aviva group companies and as required by law. We will process this information and store it on our computer and manual record systems. If you would like a copy of the details we hold about you, please write to the Compliance Manager, Hibernian Life & Pensions, One Park Place, Hatch Street, Dublin 2. Please enclose the correct fee (5). You also have the right to correct any errors in the information held about you, block certain uses or object to the processing of your personal data. Some of the questions on this form ask for details about your health and lifestyle. This information is important for underwriting purposes and will remain confidential. By signing the declaration below, you are giving us permission to process these details for the above purposes, including checking with third parties or accessing State or other official records to verify whether the details you have given are accurate and complete. By signing below, you are confirming that you understand why we asked for this information and what we will use it for. ONLY SIGN THE FOLLOWING DECLARATION IF YOU FULLY UNDERSTAND, AND HAVE MET, ALL OF THE ABOVE REQUIREMENTS. We would like to use the details to provide you with information about other products and services either from us or other Aviva group companies, or products or services which any member of the Aviva group has arranged for you with a third party. If you choose not to receive this information, this will not affect any of the services we provide to you, now or in the future. Please tick here if you wish to receive information on other products, services and special offers. If your application for insurance is declined or accepted subject to special terms then that fact may be noted on a registry administered by the Irish Insurance Federation and may be shared with other offices as a protection against non disclosure of material facts. Any changes to the answers given, before the policy comes into force, must be notified to Hibernian Life & Pensions. Telephone calls may be recorded for quality and training purposes. 1st life to be insured 2nd life to be insured Signature of Grantee(s) if different Please sign - Do not use block capitals Date Date Date In the case of a corporate grantee state name of company that authorised signatory is signing for and on behalf of Please note carefully Any change in occupation or residence must be notified to Hibernian Life & Pensions Limited during the policy term. This is a legal document and forms part of the basis of the contract. All sections must be fully completed and any alterations initialled by the signatory/signatories. Failure to provide true and complete information may render the contract void. A copy of the completed application form is available on written request by or on behalf of the proposer(s), and a copy of the policy conditions is available on request.

7 Please note: The policy number of the policy being replaced must be provided. NOTE: PLEASE ENSURE FOLLOWING DECLARATION IS SIGNED BY CLIENT AND INTERMEDIARY. WARNING: If you propose to take out this policy in complete or partial replacement of an eisting policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your eisting policy. If you are in doubt about this, please contact your insurer or insurance intermediary. Ref. Policy Number of Policies to be cancelled: Declaration of Insurer or Intermediary I hereby declare that in accordance with Regulation (1) of the Life Assurance (Provision of Information) Regulations, 2001, the applicant has been provided with the information specified in Schedule 1 to those Regulations and that I have advised the client as to the financial consequences of replacing an eisting policy with this policy by cancellation or reduction and of possible financial loss as a result of such replacement. Name of Insurer or Insurance Intermediary Signed Date LARC No. Declaration of Client(s) I /We confirm that I/We have received in writing the information specified in the above declaration. Signature: 1st life to be insured Date: Signature: 2nd life to be insured Date: For Financial Adviser use only Please ensure all relevant questions are answered before submitting the application form. 1. Name & Address 2. Agency No. 3. Name of Financial Adviser/Salesperson 4. Financial Adviser s/salesperson s address 5. Financial Adviser/Salesperson Reg. No. (LARC) 6. Start Date Please note: The policy number of the policy being replaced must be provided (see declaration). If it is not provided the eisting policy will remain in force For office use only 1. Consultant 2. Branch Date 3. Vetted by Date Direct Debit Mandate Please complete parts A to E to instruct your bank to make payments directly from your account. Your instructions to your bank. I/We instruct you, to pay direct debits from my/our account at the request of Hibernian Life & Pensions Limited. The amounts are variable and may be debited on various dates. I/We understand that Hibernian Life & Pensions Limited may change the amounts and dates only after giving me prior notice. I/We will inform the bank in writing or Hibernian Life & Pensions Limited if I/we wish to cancel this instruction. I/We understand that if any Direct Debit is paid which breaks the terms of this instruction, the bank will make a refund. A. Please complete full postal address of your Bank Branch To: The Manager Banks may refuse to accept instructions to pay Direct Debits from some types of accounts, usually savings or deposit accounts. If in doubt check with your Bank. Hibernian Life & Pensions Limited may amalgamate Direct Debits under this mandate with any other mandates payable by Direct Debit which may be due to them within the same calendar month under other mandates epressed in their favour and signed by me/us. Hibernian Life & Pensions Limited ID number Reference number office use only B. Account name C. Account number D. Bank sort code E. Signature(s) Date Application Number

8 A Hibernian Life & Pensions Limited Registered in Ireland No Registered Office One Park Place, Hatch Street, Dublin 2. Member of the Irish Insurance Federation Hibernian Life & Pensions Limited is regulated by the Financial Regulator Hibernian Life & Pensions Limited is a subsidiary of Hibernian Life Holdings Limited, a joint venture company between Hibernian Group Plc and Allied Irish Banks, p.l.c. Life & Pensions One Park Place, Hatch Street, Dublin 2. Phone (01) Fa (01) Telephone calls may be recorded for quality and training purposes.