Income Protection. Application Form. Income One. Pure Protection. Bills & Things

Transcription

1 Income Protection Application Form Income One Pure Protection Bills & Things

2 (For completion by Intermediary) Exeter Family Friendly unique reference number (if known) FCA Number Adviser Name Company Name Company Postcode Type of Sale Advised Non Advised Commission Indemnity Non Indemnity Type of Business Mortgage Business Non-Mortgage Business Important - please read before completing this application This application includes questions about your health, personal and financial circumstances. You must take reasonable care to answer all of the questions honestly and to the best of your knowledge. If you do not answer the questions correctly, your policy may be cancelled, or your claim rejected or not fully paid. If you are unsure whether or not any details are relevant, you should include them. Please note that we will not be able to offer you cover on any of our income protection plans if you have suffered from one of the following conditions: Heart attack, angina, diabetes (other than in pregnancy), rheumatoid or psoriatic arthritis, stroke, multiple sclerosis, HIV, hepatitis B, C or D. Firstly, choose how you would like to apply: Full medical underwriting Short application including tele-interview If you choose this option, you will need to complete the whole form, answering all of the questions about your health and personal circumstances. If you choose this option, you will need to complete pages 3-8 of this form, before moving to page 12 to complete your GP details, declaration and Direct Debit mandate. You will then be contacted to arrange a suitable time for your tele-interview with a trained medical professional. 2 Application Form (If you require more space please use the notes section at the back of this document)

3 Applicant details 1) Title Forename Surname 2) Sex Male Female 3) Date of Birth (You must be between the ages of 16 and 59 to apply) 4) Address Postcode 5) Telephone Mobile Telephone Occupation details 6) Main Occupation Type of Industry Employment Status Employed Self Employed Company Director Housewife/House-husband (If you require more space please use the notes section at the back of this document) Application Form 3

4 7) a) What percentage of your work could be described as the following: i) Manual (Including physical mobility, lifting or carrying) (please give details) ii) Supervisory (please give details) + % % % % + iii) Administrative % + iv) Other (please give details) = 100% (If you require more space please use the notes section at the back of this document) = 100% b) Have you been notified that you are being made redundant (if employed) or is your business in the process of being wound up (if self-employed)? Yes No If yes please give details: 8) Second Occupation (if any) 9) Do you intend to reside, work or travel outside of the UK (other than for holidays) or have you done so in the past five years? (We will not usually accept applicants who have not been resident in the UK for the last three years, please contact us for further consideration) Yes No If yes please give details: 10) Do you ever work offshore (for example on an oil rig or on a ship)? (We will not usually accept applicants who work off-shore, please contact us for further consideration) Yes No If yes please give details: 4 Application Form (If you require more space please use the notes section at the back of this document)

5 Policy details 11) Is this application: a new policy? an increase? to replace an existing policy? If you have ever had an income protection policy with us, please provide your policy number: 12) Policy Start Date Immediate To be advised If your application is not accepted at standard terms, cover will start when we have received your written acceptance of the revised terms. Product details This application form is for our 4 income protection products shown below. Please select your product on the next page and only answer the questions that are relevant to your product. It is important that you read the All you need to know or Policy Document for your chosen product while completing this section. Income One Pure Protection Bills & Things Income Protection (Holloway) Long term income protection for professional and administrative occupations. Long term income protection that covers most occupations. Long term income protection with a short term claim period; covers most occupations. Long term income protection with a with profits element. (If you require more space please use the notes section at the back of this document) Application Form 5

6 Note: Please select your product. If you are applying for Income One, use the answer boxes on this page. If you are applying for Pure Protection, Bills & Things or Income Protection (Holloway), use the answer boxes on page 7. Your personal taxable income 13) a) If you are employed, please state your personal taxable income for the current tax year b) If you are self-employed, please state your personal taxable income for the last full tax year c) If you are self-employed, please state your projected earnings for the current tax year Income One Please note that to apply for Income One you must earn a minimum personal taxable income of 20,800 per year. Your product choices When choosing your monthly benefit it is important to remember the information to the right. Depending on the benefit you choose, you may need to provide additional medical and financial evidence; please speak to your adviser if you would like to find out more about this. Benefit must not exceed 65% of your personal taxable income up to 60,000 per year and 45% in excess of 60,000. Benefit must be between 867 and 8,333 per month. 14) Monthly benefit required 15) Which premium option would you like to choose? Level guaranteed premiums Age-costed guaranteed premiums 16) Waiting Period Day 1* 1 Week* 4 Weeks 8 Weeks 13 Weeks 26 Weeks 52 Weeks You may split your cover to be payable after two separate waiting periods. If you require this facility please state: *Not available if you choose Level guaranteed premiums 2nd Monthly Benefit Required Day 1* 1 Week* 4 Weeks 2nd Waiting Period 8 Weeks 13 Weeks 26 Weeks 52 Weeks 17) Do you want the benefit to be index-linked? Yes No Do you want to fix your benefit up to a 50% proportion of your personal 18) taxable income at the time of application? (For more information about fixing your benefit, see the My Options section of the Income One All you need to know document) 19) Average business miles per annum (Excluding your travel to and from your normal place of work. Please note your annual business mileage must be below 25,000 miles to be eligible for Income One.) Yes No,000 per year 20) Finishing Age (the age at which you want the cover to cease) Finishing age must be between 50 and ) Which maximum claim period would you like to choose? To your selected finishing age. 6 Application Form (If you require more space please use the notes section at the back of this document)

7 Pure Protection Bills & Things Income Protection (Holloway) 13) a) b) c) Benefit must not exceed 65% of your personal taxable income up to 60,000 per year and 40% in excess of 60,000. Benefit must be between 78 and 10,000 per month. Benefit is not linked to earnings. Choose from the following options: ,000 Benefit must not exceed 65% of your personal taxable income. Benefit must not exceed 3,120 per month. 14) 15) Reviewable premiums Reviewable premiums Reviewable premiums 16) Day 1 1 Week 4 Weeks Day 1 4 Weeks 8 Weeks 13 Weeks 26 Weeks 52 Weeks 4 weeks 8 Weeks 13 Weeks 26 Weeks 52 Weeks Day 1 1 Week 4 Weeks Day 1 4 Weeks 8 Weeks 13 Weeks 26 Weeks 52 Weeks 8 Weeks 13 Weeks 26 Weeks 52 Weeks 17) Yes No Included as standard. Yes No 18) 19) 20) Finishing age must be between 50 and 68. Age 68. Finishing age must be between 50 and ) To your selected finishing age. 1 Year 2 Year To your selected finishing age. (If you require more space please use the notes section at the back of this document) Application Form 7

8 Your health and medical history Note: Please remember that you must take reasonable care to answer all of the following questions honestly and to the best of your knowledge. If you do not answer the questions correctly, your policy may be cancelled, or your claim rejected or not fully paid. 22) What is your height? feet inches or cm 23) What is your weight? stones lbs or kgs 24) Have you smoked or used nicotine replacement products in the last 12 months? Yes No (We may ask to carry out a simple test to verify your answer to this question) If yes please state as appropriate: Number of cigarettes per day and/or number of cigars per day and/or amount of tobacco per day gms or ozs other (including nicotine replacement products and e-cigarettes) 25) What is your average weekly level of alcohol consumption in units? Note: 1 Pint of beer/lager = 2 units, 1 125ml glass of wine = 1 unit, 1 25ml measure of spirits = 1 unit 26) Has a doctor or other medical professional ever advised you to reduce your alcohol consumption? Yes No If yes please provide full details including dates, your level of consumption at the time and over what period you consumed this level: 27) Have you ever taken drugs that were not prescribed by a doctor? (e.g. ecstasy, cocaine, heroin, cannabis, anabolic steroids etc) Yes No If yes please provide full details including type of drugs, frequency of use and date of last use: Note: If you have chosen to apply through a short application including tele-interview, move to page 12 to complete your GP details, declaration and Direct Debit mandate. 8 Application Form (If you require more space please use the notes section at the back of this document)

9 Note: If you have chosen to apply through full medical underwriting; please complete the following questions regarding your health and medical history. 28) Have you ever had any of the following? a) Diabetes or any disorder of the heart, arteries or veins including heart attack, angina, heart defects from birth or heart surgery? Yes No b) Any disease or disorder of the neurological system including multiple sclerosis (MS), paralysis, Parkinson s disease, stroke, brain injury or epilepsy? Yes No c) Mental illness (including anxiety, stress or depression), addiction, eating disorders, severe fatigue or nervous breakdown? Yes No d) Cancer, leukaemia, lymphoma, brain or spinal tumour? Yes No e) Rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or any form of neck, back, spine or joint surgery? Yes No f) More than one consecutive month off work due to health issues? Yes No g) HIV, hepatitis B, C or D or are you awaiting the results of such a test? Yes No If you have answered yes to any of the above questions, please provide full details including dates, diagnosis and medication given: 29) In the last 5 years have you had any of the following? (You must also tell us about any symptoms that you have had but have not yet seen a doctor about) a) Back or neck pain or any other symptoms, disease or disorder affecting the back or neck? (Including arthritis, slipped disc, sciatica or whiplash) Yes No b) Joint pain or arthritis or any other symptoms, disease or disorder affecting the joints, ligaments, bones or muscles (including any conditions or pain affecting your shoulders, knees, hips, ankles, wrists or hands) Yes No c) Raised blood pressure or cholesterol readings (whether or not you needed treatment or follow up) or chest pain or irregular heart beat? Yes No d) Numbness, pins and needles, change in skin sensation, balance problems, dizziness or difficulty with co-ordination or walking? Yes No e) Impaired hearing or vision, including blurred or double vision, or any other disease or disorder of the eyes or ears including tinnitus, Meniere s disease or labyrinthitis? (You do not need to tell us about impaired vision which is fully corrected with glasses or lenses) Yes No f) Asthma, hay fever, bronchitis or any other lung or breathing problems? Yes No If you have answered yes to any of the above questions, please provide full details including dates, diagnosis and medication given: Note: If you have answered yes to questions 28 c), 29 a) or 29 b), we will require you to complete a further questionnaire which can be downloaded from the forms section of our website. (If you require more space please use the notes section at the back of this document) Application Form 9

10 30) Apart from anything that you have already told us about, in the last 5 years have you: a) Had, or been advised to have any medical investigations? (e.g blood tests, MRI/CT/ultrasound scans, x-rays, ECG or other heart tests). You do not need to tell us about tests in association with pregnancy. Yes No b) Attended a hospital or other clinic as an inpatient or outpatient or are you awaiting such a referral? Yes No If you have answered yes to any of the above questions, please provide full details: 31) Apart from anything that you have already told us about, in the last 2 years have you: a) Been subject to medical review with a doctor, medical centre or clinic? You do not need to tell us about pregnancy reviews or fertility treatment. Yes No b) Been prescribed any medication or treatment (including a course of counselling)? You do not need to tell us about contraception, HRT or fertility treatment. Yes No c) Had more than 10 consecutive days off work or had any limitation or restriction on your ability to do your occupation? Yes No If you have answered yes to any of the above questions, please provide full details including dates, diagnosis and medication given: Your Family History 32) Have your parents, brothers or sisters suffered from any of the following prior to the age of 65: a) Bowel, breast or ovarian cancer (please advise which type below) Yes No b) Heart disease, high blood pressure or stroke (please advise which) Yes No c) Multiple sclerosis Yes No d) Diabetes Yes No e) Cardiomyopathy Yes No f) Polycystic kidney disease Yes No g) Polyposis coli Yes No h) Any other hereditary disease Yes No If you have answered yes to any of the above questions, please provide full details including family member, description of the condition and age at diagnosis: 10 Application Form (If you require more space please use the notes section at the back of this document)

11 Sports and Hobbies 33) a) In the last 5 years have you taken part in any of the following sports or hobbies or do you intend to do so? Martial Arts Yes No Scuba diving Yes No Off-piste skiing or snowboarding Yes No Kitesurfing Yes No Horse riding (other than private hacking) Yes No Outdoor rock climbing/mountaineering Yes No Motor sports Yes No Aviation Yes No Mountain biking (other than along flat paths) Yes No b) Do you participate in any sport in a semi-professional or professional capacity? Yes No If you have answered yes to any of the above questions, please provide full details: (If you require more space please use the notes section at the back of this document) Application Form 11

12 GP Details Please give details of the doctor with whom you are currently registered. (Please note we will not automatically obtain a medical report from your doctor) Doctor s Name Surgery Address Postcode Telephone If you have been with your GP for less than a year, please also provide details of your previous GP in the notes section at the back of this document. IMPORTANT NOTES Please remember that all of the information requested in this application form is taken into account when we are assessing your application and calculating your premium. If you do not provide us with complete and accurate information, it may lead to us not only declining any claim you make, but also cancelling your policy. If after submitting the application and before the policy starts there are any changes to your health or personal circumstances (this includes a change in occupation or take up of a hazardous hobby) you should notify us immediately. The information you provide on your application form will be used by us for underwriting and administering your policy, including transmission to those involved in your treatment or care and for the purposes of providing any add-on services related to your policy. Any information which you have provided relating to your health or lifestyle is required for underwriting purposes and is defined as sensitive data by the Data Protection Act The information will be held securely and access limited to those who need to see it. We may need to send your application and relevant medical reports to our reinsurers or any third parties for their opinion or agreement of the terms offered. Or we may need to send them at a later stage for purposes relating to managing the policy. ACCESS TO MEDICAL REPORTS ACT 1988 Summary of the main points contained in the Act. The provisions noted in the Act above became effective from 1st January 1989 and before we can apply for a medical report from your doctor we not only need your consent but must offer you the right to see the report before it is sent to us. There are a number of rights under this act of which you should be aware and these are set out below as follows: 1) You may withhold your consent. 2) You have the right to see the report before it is sent to us provided that you apply to the doctor within 21 days. If you choose not to see the report at this stage, you may ask the doctor for a copy within 6 months of it being sent to us. The doctor may charge you a fee for supplying the report. 3) You can ask the doctor to amend any part of the report which you consider to be incorrect or misleading and if the doctor does not agree you may append your comments. 4) The doctor can withhold part or all the report from you if he has reasons why he thinks you should not see it. 5) The medical report your doctor fills in asks about the following: - Your current health - Any care, medication or treatment you are currently receiving - The results of referrals or tests you are waiting for - Any time off work - Your past health - Details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultations 12 Application Form (If you require more space please use the notes section at the back of this document)

13 with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of: - Malignancy (cancer), cardiovascular (heart) disease, diabetes and degenerative (gradually worsening) disease - Musculoskeletal disease or injury, for example, arthritis, rheumatism, back problems or any other disorder of the joints or muscles - Anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose contact with reality), stress or fatigue - Suicidal thoughts or attempts at suicide - Conditions related to drug or alcohol misuse or smoking or chewing tobacco - Details of any biopsies, blood tests, electrocardiograms (heart tests) height, weight if measured, urinalyses (tests on urine) x-rays or other investigations - Any blood pressure readings - Any history of disease among your parents or brothers or sisters that you have told the doctor about If we require more information from your GP, we won t ask them to reveal any information about: - Negative test for HIV, hepatitis B or C - Any sexually transmitted disease unless there could be long-term effects on your health - Predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from. The information you and your doctor provide about your health may result in us: - Setting premiums at standard rates - Increasing premiums above standard rates - Imposing exclusion clauses - Refusing to provide insurance If you have any questions about your rights under the Act or questions relating to the process of getting, accessing or storing medical information, please write to the Chief Medical Officer at: Exeter Family Friendly, Lakeside House, Emperor Way, Exeter EX1 3FD. DECLARATION I, the undersigned: a) Having read the explanation of my rights under the Access to Medical Reports Act 1988 (see page 12) consent to you Exeter Family Friendly seeking information in connection with this application from any doctor who has at any time attended me concerning anything which affects my physical or mental health and authorise the giving of such information by such doctors; I do/do not require to see any report before it is issued. (Please delete as appropriate). b) Declare that my answers to the questions given in the application form and as part of any telephone interview are complete and correct to the best of my knowledge and belief. I understand that you will rely upon my answers both written and verbal which together with your standard policy terms and conditions contained in the All you need to know will form the basis of the contract between myself and Exeter Family Friendly. For your own benefit and protection you should read the terms and conditions before signing them. If you do not understand any point please ask us for further information. Signature Date (If you require more space please use the notes section at the back of this document) Application Form 13

14 Notes Question Number 14

15 Originator s Identification Number Reference Number (For Exeter official use only) Min/Max Characters: 6/18 INSTRUCTION TO YOUR BANK OR BUILDING SOCIETY TO PAY BY DIRECT DEBIT Please fill in the whole form using a ball point pen and send it to: Exeter Family Friendly Lakeside House Emperor Way Exeter EX1 3FD NAME AND FULL POSTAL ADDRESS OF YOUR BANK/BUILDING SOCIETY BANK/BUILDING SOCIETY ACCOUNT NUMBER THE MANAGER BRANCH SORT CODE Your instruction to the Bank or Building Society Please pay Exeter Friendly Society Ltd (EFS) Direct Debits from the account detailed on this instruction, subject to the safeguards assured by the Direct Debit Guarantee. NAME(S) OF ACCOUNT HOLDER(S) I understand that this instruction may remain with EFS and, if so, details will be passed electronically to my Bank/Building Society. SIGNATURE DATE / / Banks and Building Societies may not accept Direct Debit instructions for some types of accounts. This guarantee should be detached and retained by the payer THE DIRECT DEBIT GUARANTEE This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Exeter Friendly Society Ltd (EFS) will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request EFS to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by EFS or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when EFS asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

16 Design - EFF_5054 Exeter Family Friendly, Lakeside House, Emperor Way, Exeter EX1 3FD Members: T: e: member@exeterfamily.co.uk Financial Advisers: T: e: adviser@exeterfamily.co.uk Calls may be recorded and monitored Exeter Family Friendly is a trading name of Exeter Friendly Society Limited, which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Exeter Family Friendly is incorporated under the Friendly Societies Act 1992 Register No. 91F with its registered office at Lakeside House, Emperor Way, Exeter, England EX1 3FD. 2014/1243