Use a separate piece of paper if you need any more space for any of your answers but please sign and date it.

Transcription

1 Alteration Form

2 NOTES Please read these notes carefully before completing the application form. Please make sure that you: Use blue or black ink; Use BLOCK CAPITALS throughout; Correct and initial any alterations. Do not use correction fluid; Complete all relevant sections as fully as possible; Use a separate piece of paper if you need any more space for any of your answers but please sign and date it. On your request, we will send you a copy of your application form and a copy of the relevant master terms and conditions. All the questions on this application form will be considered by the specific Assurance Company in assessing the acceptability of your application. All answers must therefore be carefully considered. Material facts (i.e. those likely to influence the Assurance Company s assessment and acceptance of the application) must be disclosed, as not disclosing them may result in the rejection of a claim and your policy may be made void. If you have any doubt as to whether a fact is material then you should disclose it, but see genetic testing below. Genetic Test Results If this application, taken together with any other insurance policies you already have, is for life insurance up to a sum of 500,000 or critical illness up to 300,000 you need not disclose any genetic test you may have had. You need not disclose the results of any genetic test undertaken in the context of research. Genetic test results need only be disclosed where the sum exceeds either 500,000 for life insurance or 300,000 for critical illness and their use by insurers has been independently approved. You may, of course, disclose any genetic test result, which is in your favour. If you either have a family history of, or are experiencing symptoms of, or are having treatment for, a genetic condition, you must tell the Assurance Company. Further information is available on request, which fully explains this Plan and details of the genetic tests approved for use by insurers. 2

3 PERSONAL AND OCCUPATIONAL DETAILS Plan Number Surname Title First Names Current Address It is essential that you enter your post code Telephone Number Day/Work Evening/Home National Insurance Number Date of Birth What is your occupation? What is your jobdescription? REVISED MORTGAGE DETAILS New Mortgage Address (if applicable) PLAN REQUIREMENTS - Please confirm the full revised amount required Required Maturity Value of NISA New Mortgage Amount Assumed Annual Growth Rate (between 5% - 9%) % Remaining Plan Term Years The Required Maturity Value may equal the New Mortgage Amount or if there are dual applicants, may be half of the amount of the mortgage or another proportion. Please ensure the correct Required Maturity Value is disclosed as this affects the amount of the rmal Regular Subscriptions. The New Mortgage Amount is the amount upon which any Mortgage Interest Payments are to be calculated i.e. Long Term Sickness and Unemployment. Please specify the growth rate to be assessed in calculating your monthly rmal Regular Subscription to achieve the Required Maturity Value of your NISA. Unless you specify otherwise a 7% annual growth rate will be used. REVISED PROTECTION BENEFITS - Please confirm the full revised amount required These benefits will be provided by the associated Assurance Company. Life Assurance and Critical Illness Benefits Either A. Life Assurance (which includes Terminal Illness Insurance) Type of Benefit Tick One Box Only Decreasing term plus the value of your NISA (this provides the precise amount required on death) or Level term plus the value of your NISA (this provides the value of your NISA in addition to the required insured amount) With optional Additional Stand Alone Critical Illness Benefit (which includes Total Permanent Disability Insurance) This amount will be level and is payable in addition to any life assurance benefit and the value of your NISA. or B. Life Assurance or earlier Critical Illness Benefit (which includes Terminal Illness and Total Permanent Disability Insurance) 3

4 REVISED PROTECTION BENEFITS (Continued) - Please confirm the full revised amount required Type of Benefit Decreasing term plus the value of your NISA Level term plus the value of your NISA Tick One Box Only (this provides the precise amount required on death or earlier critical illness) or (this provides the value of your NISA in addition to the required insured amount) With optional Additional Stand Alone Critical Illness Benefit (which includes Total Permanent Disability Insurance) This amount will be level and is payable in addition to any life or earlier critical illness benefit and the value of your NISA. Long Term Sickness and Unemployment Benefit - Tick or as appropriate Long Term Sickness Protection (sickness, accident or disability) Plan Subscriptions Mortgage Interest Payments Plan Subscription Cover is for the amount of your rmal Regular Subscription to your Plan. Mortgage Interest Payments Cover will be based on the New Mortgage Amount you have shown on page 1. REVISED NORMAL REGULAR SUBSCRIPTION - Please confirm the full revised amount required New Total rmal Regular Subscription Complete only if a fixed premium is required. If left blank this will be calculated for you based upon the maturity value requested (NB. due to market conditions premiums may fluctuate on a daily basis). Preferred monthly day for direct debit collection (1st -28th day) ALTERATION DATE DETAILS (A) The Plan is to be amended immediately on acceptance (B) The Plan is to be amended upon receipt of confirmation from me / my agent If any benefit you apply for is not accepted at ordinary rates we will refer back to your Independent Financial Adviser, irrespective of instructions given above. Please note: The commencement date cannot be backdated. HEALTH AND OTHER INFORMATION You must disclose ALL facts which are likely to influence the assessment of this application. Genetic Test Results If this application, taken together with any other insurance policies you already have, is for life insurance up to a sum of 500,000 or critical illness up to 300,000 you need not disclose the results of any genetic test you may have had. You need not disclose the results of any genetic test undertaken in the context of research. Genetic test results need only be disclosed where the sum exceeds either 500,000 for life insurance or 300,000 for critical illness and their use by insurers has been independently approved. You may, of course, disclose any genetic test result, which is in your favour. If you either have a family history or are experiencing symptoms of, or are having treatment for, a genetic condition, you must tell the Assurance Company. Further information is available on request, which fully explains this Plan and details of the genetic tests approved for use by insurers. If you are in doubt as to the relevance of any particular information you should disclose it, as failure to do so might affect the benefits payable. If the answer to any of the questions is YES, please give full details (including the name of the doctor who treated you, if other than your usual doctor) in the space below question 10, or if more space is required then on a separate piece of paper and sign and date it. 1. Have you consulted your doctor or any other doctor, or been advised to have an operation, x-ray, check up or investigation in the past 3 years? You may ignore minor ailments requiring a single consultation and normal childbirth Tick One Box Only 2. Have you or any of your natural parents brothers or sisters suffered or died before age 60 from any of the following or from any other hereditary disorder: - hypertension, heart or circulatory disorders or stroke - cancer, tumours or growths - diabetes, kidney disease - multiple sclerosis, paralysis or any other disorder of the brain or nervous system - huntington s chorea? Please indicate whether the history relates to you, parent(s) or siblings, and include the date and age at diagnosis and the site of any cancer or tumour. 4

5 HEALTH AND OTHER INFORMATION (continued) 3. Have you ever suffered from any: - mental or nervous illness (including anxiety, depression or stress) - recurrent ear or eye disorder - arthritis, or any back, spine or other recurrent joint disorder - asthma, bronchitis or any other chest complaint? 4. Do you belong to any of the following high risk groups for HIV infection; homosexual or bisexual males; intravenous drug abusers; haemophiliacs; sexual partners of the aforementioned or someone who is, or was HIV positive; or have you lived or travelled regularly to an area which has a high incidence of infection, or have you ever tested positive for HIV/AIDS or are you awaiting the results of such a test? If you belong to one of the above high risk groups please make sure that you state which one in the box below. 5. Are you suffering from any illness, impairment or disability not already mentioned above or are you taking any medication or drugs? 6. Has any proposal on your life ever been declined, deferred or accepted on special terms or withdrawn? 7. Have you used any tobacco products in the last 12 months? If yes state your average WEEKLY usage: Type of product Cigarettes Cigars Pipes (number per week) (number per week) (ounces per week) 8. What is your average WEEKLY consumption of alcohol in units? (units per week) One unit is defined as 1/2 pint of beer, or 1 glass of wine, or 1 measure of pub spirits. 9. What is your height and weight (indoor clothing without shoes)? Height Weight (ft/in or m/cm) (st/lbs or kgs) 10. Have you any intention of going abroad (other than for holidays of up to a month) or engaging in any hazardous sport or pastime or in flying (other than as a fare paying passenger)? Hazardous pursuits could include sports such as hang gliding, rock climbing and motor racing. 5

6 DOCTORS DETAILS Please provide details of your current doctor: Name Address Telephone Number Please give details of your previous doctor if you have changed doctor in the last 6 months. See this page and page 5 for consent to access to personal files and medical reports. Name (previous doctor) Address Telephone Number ACCESS TO MEDICAL REPORTS The Assurance Company or their agent may wish to approach your doctor for a medical report concerning your health. Before this is done, you will be notified so that you can, if you wish, exercise your rights under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (rthern Ireland) Order Your rights These rights are summarised below: (a) (b) (c) (d) You have the right to arrange with your doctor to see the report before it is sent to The Prudential Assurance Company Limited orduring the 6 months after that; You have the right to withhold your consent to your doctor sending a report to The Prudential Assurance Company Limited; You have the right to ask your doctor to change parts of the report you consider to be inaccurate or misleading. (If your doctor is not in agreement with the changes, you may add your own comments to the report.) You should be aware that your doctor can withhold the report (or part of it) from you, if he thinks you would be harmed by seeing it. DECLARATION to the Assurance Company I declare that I am in good health and free from disease (except as stated) and I consent to the the associated Assurance Company seeking medical information from any insurance office to which an application has been made for insurance on my life and I authorise the giving of such information. I undertake to notify the Assurance Company in writing of any change in my medical or other circumstances between the date of completing this proposal and the date on which I receive notice of the Assurance Company s normal terms of acceptance or the date I sign my agreement to alternative terms offered by the Assurance Company and I agree to accept the usual form of Certificate and to be bound by the Master Terms and Conditions. I have read the notes describing my rights under the Access to Medical Reports Act 1988 and the Access to Personal Files and Medical Reports (rthern Ireland) Order 1991 and I consent to The Associated Assurance Company seeking information from any doctor who has attended me concerning my physical or mental health. I understand I will be notified if such a report is requested by the Assurance Company. I wish to see the report before it is sent to the Assurance Company. Unless I have ticked the box above I confirm that I do not wish to see the report before it is sent to the Assurance Company. I am aware that I may approach my doctor with a request to see a copy of the report within 6 months of its completion. I apply for the insurances indicated above and agree to be bound by my Plan Terms and Conditions. Tick as appropriate NOTE: Submission of a completed application form does not imply commencement of the protection risk. A letter of acceptance from Synergy Financial Products Limited on behalf of the Assurance Company will indicate the insurance risk is acceptable. Any omission or mis-statement of material facts, even if they are outside the scope of the questions asked, could affect payment of benefit(s) under the Plan. Material facts are those which an insurer would regard as likely to influence the assessment and acceptance of an application. If you are in any doubt as to whether a particular fact is material, then you should disclose it, but refer to the Genetic Test Results paragraph on page 2. 6

7 Please note: Insurers share information with each other to prevent fraudulent claims via the Register of Claims. A list of participants and the name of the operative is available on request. In the event of a claim, the information you have supplied on this form and the claim form, together with other information relating to the claim, will be provided to Registered participants. DATA PROTECTION ACT Data Protection Act 1998 Synergy Financial Products Limited is a data controller within the meaning of the Data Protection Act You hereby consent to such use by Synergy Financial Products Limited of the personal information given under this contract as may be reasonably necessary in providing services to you and in updating its customer records. Such information may also be used by Synergy Financial Products Limited and its Associates to advise you of other products or services. You are entitled to have access to the information we hold about you upon payment of a fee. If you would prefer not to receive such information please tick the following box. te: Your signature embraces all of the relevant declarations and authorises the above. Signature Date Please note that a copy of the Master Terms and Conditions on which the insurance will be made is available on request, and that a copy of this completed proposal form will also be available on request. Synergy Financial Products Limited: PO Box 1010, St Albans, AL1 9NB Authorised and regulated by the Financial Conduct Authority which can be confirmed at Registered address: 45 Grosvenor Road, St Albans, AL1 3AW. Registered in England and Wales number: Tel: Website: sfpl.co.uk support@sfpl.co.uk AF