Group Income Protection Insurance - Employer s Questionnaire

Transcription

1 Group Income Protection Insurance - Employer s Questionnaire Employee Name Please complete all sections as fully as possible using black ink. You can attach separate sheets, as necessary. If you are in any doubt as to whether you need to disclose a particular fact to us, please state it in full. Once completed and signed, please post this questionnaire, together with the following items, to us at: Claims Dept, Unum, Milton Court, Dorking, Surrey, RH4 3LZ. Alternatively them to us at DorkingClaimsAdmin@unum.co.uk: 1. Job Description 2. Absence records for the two year period prior to the employee s absence 3. Proof of age a. An original birth certificate and b. Proof of any subsequent name change (e.g. original marriage, divorce or deed poll documents) The above proof of age documents are only required if the age of the employee has not been admitted for employment or pension purposes. Timetable for submission of claims: 13 week deferred period - no more than 4 weeks after incapacity begins a deferred period of more than 13 weeks - no more than 10 weeks after incapacity begins Should you have any queries, please contact us on Please note: As part of the claims assessment process, one of our Claims Management Specialists may telephone the claimant directly. The purpose of this contact is to gather information to assist with the early delivery of a decision. Please be assured that no policy or payment details will be discussed unless agreed with you. Our Rehabilitation and Health Management Team may be able to help your employee to return to work. We can guide you on reasonable adjustments where these may be needed and we can help you build return to work plans. If it is appropriate, our Rehabilitation and Health Management Team may contact you regarding the services we can provide. Alternatively, you can call our Rehabilitation and Health Management Team on to discuss the support available to you and your employee. page 1 of 8 UP333a 03/2015

2 Section 1 - Eligibility Details Life ID (if known) Policy Number Name of scheme Contact Name Company Address Contact Telephone Number Contact Employee Name Employee Address Date of Birth Employee Telephone Number If you have confirmed the employee s date of birth for employment or pension scheme purposes, please tick here. Alternatively, please enclose proof of age in the form of your employee s original birth certificate and proof of any subsequent name change (e.g. original marriage, divorce or deed poll documents). Date of commencement of continuous absence (dd/mm/yyyy) (please enclose absence record) Salary prior to incapacity (as defined in Scheme s Rules) Date joined company s service (dd/mm/yyyy) Date joined Scheme (dd/mm/yyyy) Scheme Category Date eligible to join Company Pension Scheme (dd/mm/yyyy) Date joined Company Pension Scheme (dd/mm/yyyy) Has employment been terminated? Yes No If Yes please advise date Is the member on a fixed-term contract or engagement? Yes No If Yes please provide the contract end date as at the commencement of continuous absence At what stage does their salary reduce during absence and to what level? Percentage of pension fund contributions insured % Is National Insurance contracted in or out? In Out Is the employee eligible for Private Medical Insurance? Yes No (e.g. BUPA, PPP, AXA, etc) If Yes, at what level? page 2 of 8 UP333a 03/2015

3 Section 2 - Absence Details Nature of illness/injury/condition (if known) Name of employee s medical practitioner Address Details of current treatment (if known) To what extent is the injury, illness or condition affecting the employee s ability to carry out the main activities in his/her role? Prior to absence, was the employee able to complete tasks to the required standard? If not, please provide details. Were/are there any performance/disciplinary/attendance issues? If so, please provide details (including absence records) Has the treating medical practitioner indicated whether the employee can return to work on a modified basis? (Please tick below as appropriate) On a phased basis Amended duties Altered hours With workplace adaptations Please give details, including any recommendations for reasonable adjustments or recovery time Has a return to work date been discussed or agreed? page 3 of 8 UP333a 03/2015

4 Section 2 - Absence Details continued Have adjustments been made to the employee s role? Yes No If Yes, please provide details and indicate whether the adjustments have been successful Has objective testing of the employee s ability to work been carried out by your company/your Occupational Health Provider, etc? Yes No If Yes, please provide details of objective tests (eg Vocational Assessment, Functional Capacity Assessment) Has a home visit been carried out by your company? (e.g. by Human Resources, Occupational Health, Line Manager) Yes No Please provide details of how you would like unum s Rehabilitation and Health Management Services to assist in this case. Section 3 - Occupation Details (to be completed by the employee s line manager) This section contains detailed information of the employee s occupation, including a description of the fundamental duties and demands of the job, as well as details of any adjustments or modifications to those duties. This section should be completed by the employee s line manager, if possible. 1. Details of Employment Name of employer and place of work Telephone number Type of industry What is the employee s job title? page 4 of 8 UP333a 03/2015

5 Section 3 - Occupation Details continued Please describe the required and essential duties of the employee s job in detail, including any special intellectual demands (e.g. communications, calculation, problem solving, etc). Non-essential duties should not be included. Please note: the employer must investigate and implement any reasonable adjustments to the working conditions, the physical features and other arrangements of the employee s occupation which would enable the employee to continue working. The employer must also investigate and, where appropriate, make reasonable efforts to implement any rehabilitation and reintegration programmes to enable the employee to return to work. 2. Work environment In what area does the employee work (e.g. office, outdoors, factory, etc)? If more than one, please indicate the percentage of time spent in each area. What machines, tools or special equipment (if any) does the employee operate? Does the job require exposure to dust, fumes, heat or cold, noise or any other specific environmental conditions? Yes No If Yes, please give details Does the job require lone working, working at heights, working in confined spaces or the use of specialised personal protective equipment (e.g. respirators, breathing apparatus, etc)? Yes No If Yes, please give details page 5 of 8 UP333a 03/2015

6 Section 3 - Occupation Details continued 3. Physical requirements of job Please tick box applicable to those patterns of work which most closely apply to the daily activities of this employee. Please feel free to annotate or modify these patterns in the interest of accuracy. Physical Demand Characteristics: Work Pattern (Lifting/Carrying) Sedentary Light Medium Heavy Very Heavy Seldom (less than 15% of the work day) Occasional (16%-33% of the work day) 5kg (10 lbs) 5kg (10 lbs) Frequent (34%-66% of the work day) 10kg (20 lbs) 10kg (20 lbs) 5kg (10 lbs) push/pull of arm/ leg controls while standing Constant (more than 67% of the work day) push/pull of arm/ leg controls while standing 25kg (50 lbs) 25kg (50 lbs) 10kg (20 lbs) 5kg (10 lbs) 50kg (100 lbs) 50kg (100 lbs) 25kg (50 lbs) 10kg (20 lbs) over 50kg (100 lbs) over 50kg (100 lbs) over 25kg (50 lbs) over 10kg (20 lbs) Percentage of day spent: Driving (excluding travel to and from work) Please specify type of vehicle Prolonged periods in one posture Please specify posture Walking Bending / Stooping Crawling / Kneeling Climbing stairs Climbing ladders or similar Reaching / Stretching Please attach additional sheets if necessary 10% 20% 30% 30-50% over 50% page 6 of 8 UP333a 03/2015

7 Section 3 - Occupation Details continued 4. Hours of Work What are the employee s normal weekly contractual hours? Total per week Do any of the following apply? From To AM / PM AM / PM Shift Work Yes No Weekend Work Yes No Being on Call Yes No 5. Job Skills Does the employee have management or supervisory responsibilities? Yes No If Yes, how many staff does the employee directly manage/supervise? What qualifications, skills and/or experience are required to perform the occupation? 6. Travel Does the employee s job involve travelling Yes No If Yes, how many miles per week? How does the employee travel? Please attach additional sheets if necessary Section 4 - Payment Details Name and address of the employer s bank to which benefit payments should be made if the claim is admitted Bank Name Bank Address Name of Company Account Bank Sort Code Bank Account No. page 7 of 8 UP333a 03/2015

8 Section 5 - Declarations Check List Please remember to include the following items with this form: 1. Job Description 2. Absence Records 3a. Original Birth Certificate (not required if box on page 2 is ticked) 3b. Original documents for proof of name change (not required if box on page 2 is ticked) Declaration I declare that all statements made are true and complete to the best of my knowledge and belief and that I have disclosed all information material to this claim for benefit. I understand that if any information provided is found to be deliberately misleading, or if I fail to provide material information, this claim may be rejected and the insurer may be entitled to keep any premiums paid. Signed Date (dd/mm/yyyy) Full name Position in company unum.co.uk Unum Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Registered in England We monitor telephone conversations and communications from time to time for the purposes of training and in the interests of continually improving the quality of service we provide. Copyright Unum Limited 2015 Registered office: Milton Court, Dorking, Surrey RH4 3LZ TEL FAX page 8 of 8 UP333a 03/2015