Data capture form for telephone application
|
|
- Marjory Jacobs
- 8 years ago
- Views:
Transcription
1 PERSONAL MENU PLAN Data capture form for telephone application Information for advisers how to use our telephone application service To apply for a Royal London Personal Menu Plan, simply go to adviser.royallondon.com and log in to quote and apply. You ll be given the option to apply by telephone application where you can enter the information you ve captured from this form. Or, if your client is present, you can just enter the information we need directly. We will then call your client and ask them questions about their lifestyle and health that are relevant to their application. If two people are applying then we will have to speak to both of them but we can do this with separate calls. We will make appointments to speak to your client over the next 14 days, excluding Sundays and most public holidays. The times we use to make appointments are as follows: Monday Thursday between 8.30am and 8.45pm, Friday between 8.30am and 6.45pm and Saturday between 8.30am and 3.45pm. After the telephone call(s), we ll send your client a copy of the answers they ve given us. We ll ask them to confirm that the information provided is accurate and complete by signing and returning a confirmation form within 60 days. Important information for the person completing this form It s very important that you tell us if there s a change to any of the answers to the questions within the application (including in relation to the person covered s health, occupation or leisure activities) or any other information you or the person covered provide between the date the answer or information is provided and the date we start the plan. If you don t do this, and this affects the terms that we would offer you, your plan may be cancelled and may not pay out in the event of a claim. You can ask us for copies of the plan details, key facts, the completed application form and the ABI genetic testing code of practice. If you ve had a predictive genetic test for Huntington s disease, you only have to tell us the results if this application, when added together with any cover you have of the same type, is for more than: 500,000 of Life Cover 300,000 of Critical Illness Cover or Life or Critical Illness Cover, or 30,000 each year of Income Protection. However, if you ve had any genetic test and the results are in your favour, you can choose whether to tell us the results or not. You must tell us however, if you think you re having treatment for, or are experiencing symptoms of, a genetic condition. For financial advisers Quote number Protection Personal Menu Adviser name Account number Special commission instructions Your unique reference Page 1 of 13
2 1 Who will be the plan owner? Please remind your clients how important it is to answer all the questions on this form honestly and in full. Will the person or people covered also be the plan owner(s)? Yes No If Yes, please go to section 2. Title Mr Mrs Miss Ms Other (please give details) First name(s) Surname Date of birth D D M M Y Y Y Y What is the plan owner s relationship to the person or people covered? Wife Husband Civil partner Partner/co-habitant Common law spouse Business partner Company Employer Other If Other, please give details In which country is the plan owner permanently resident? UK Guernsey Other Jersey Isle of Man If Other, please give details In the next six months, will you be moving from the country in which you re permanently resident? If Yes, please give full details. What is the plan owner s address? Yes No Postcode Phone number Page 2 of 13
3 2 About the people covered Please remind your clients how important it is to answer all the questions on this form honestly and in full. Person 1 Person 2 Title Mr Mrs Miss Ms Mr Mrs Miss Ms Other (please give details) Other (please give details) First name(s) Surname Date of birth Gender Your gender doesn t affect the premium. D D M M Y Y Y Y D D M M Y Y Y Y Male Female Male Female Marital status What is your relationship to person 1? Married Living together as partners Divorced Widowed Single Separated Civil partnership Surviving civil partner Married Living together as partners Divorced Widowed Single Separated Civil partnership Surviving civil partner Wife Husband Civil partner Partner/co-habitant Common law spouse Business partner Company Employer Other If Other, please give details Your home address Postcode If you move house while we re processing your application, please contact us once you ve moved to your new address. Page 3 of 13
4 2 About the people covered continued Person 1 Person 2 In which country are you permanently resident? UK Jersey UK Jersey Guernsey Isle of Man Guernsey Isle of Man Other If Other, please give details Other If Other, please give details In the next six months, will you be moving from the country in which you re permanently resident? If Yes, please give full details. Yes No Yes No Phone number Daytime Evening Daytime Evening Page 4 of 13
5 3 Additional information Page 5 of 13
6 4 GP details Name of doctor or practice Person 1 Person 2 Address Postcode Phone number If you ve changed GP in the last six months, please give the details of your previous GP in the additional information section on page 5. 5 Premium payment details Is the person paying for the plan the plan owner? If Yes, please go to payment frequency question. Account name Yes No What is the plan payer s relationship to the plan owner(s)? Wife Husband Civil partner Partner/co-habitant Common law spouse Business partner Company Other First name(s) Surname We may need to verify the identity of the person paying for this plan. So that we can do this, please give us their home address and date of birth. Address Postcode Date of birth D D M M Y Y Y Y Payment frequency Monthly Yearly Page 6 of 13
7 5 Premium payment details continued Payment day Which day would you prefer us to collect your premiums? Please choose between 1st - 28th of each month. Sort Code Account number 6 Start date a) The plan is to start on the date shown D D M M Y Y Y Y b) The plan is to start as soon as we accept it c) To be advised 7 Important notes References to we, us and our refer to the Royal London Mutual Insurance Society Limited (Royal London), which is part of the Royal London Group. The Royal London Group consists of the Royal London Mutual Insurance Society Limited and its subsidiaries, including Royal London Marketing Limited. We may need to share the application information with our agents (such as underwriters, reinsurers, and medical agencies), for the purposes of requesting medical information or arranging examinations. If you re applying for insurance with other companies at the same time as this, by signing the declaration you re agreeing to copies of any medical reports prepared on your behalf being shared between Royal London and these other companies. If, however, another company asks us to provide copies of highly sensitive information (for example HIV test results), we ll ask for your written permission before we do so. We may ask you to contact your doctor if we re waiting for reports we ve asked for. You can ask us for a copy of the key facts, plan details, cover summary or your application form at any time. The plan won t start until we ve assessed and accepted your application, and we ve received a Direct Debit mandate. If you re resident in: the UK, your plan will be governed by the law of England & Wales. Jersey, Guernsey or Isle of Man, your plan will be governed by the law of England and held under Seal; unless otherwise agreed with Royal London. If you ve applied for Unemployment Cover or Waiver of Premium (Unemployment), your contract for those benefits will be provided by UK General Insurance Ltd on behalf of UK General Insurance (Ireland) Ltd. Royal London Marketing Limited will make this insurance available as a cover under the plan on behalf of UK General. Remember you must tell us about any change of personal health, your family s medical history, any occupational change, participation in hazardous pursuits, travel or residence between now and the date the plan starts. If you don t do this, and this affects the terms we would have offered you, your plan may be cancelled and may not pay out in the event of a claim. You can ask us for details of any company we use to assess your application, by writing to us at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. Page 7 of 13
8 8 Data protection How we use your personal information We, the Royal London Mutual Insurance Society Limited (and our businesses and divisions) may obtain personal information either from you directly, or with your consent, from your approved intermediary or from other sources such as your doctor or an identity authentication agency. We ll use your personal information (including sensitive personal information) for the following purposes: Providing and developing our products and services Improving customer care Verifying your identity and fraud prevention Research and analysis Marketing Legal and regulatory reasons Administering your plan We ll keep your personal information for a reasonable time and we may also share information about you with other companies within the Royal London Group, your approved intermediary, our service providers and agents and with third parties such as auditors, underwriters, reinsurers, medical agencies, identity authentication and fraud prevention agencies, other financial institutions and legal and regulatory bodies. Your personal data may be processed in countries outside the European Economic Area. This processing will be carried out by experienced and reputable organisations and only on terms which safeguard the security of your data and comply with the requirements of the Data Protection Act We may contact you by mail, phone, fax, or other electronic messaging either directly or through your approved intermediary with further offers, promotions and information about our products and services that may be of interest to you. By providing us with this information you consent to being contacted by these methods for these purposes. Please tick this box if you don t wish to receive these communications. Plan owner Person 1 Person 2 We may carry out an identity authentication check to verify your identity. This involves checking the details you supply against those held on any databases that may be accessed by the reputable third party company which carries out our checks. This includes information from the electoral register and fraud prevention agencies. We ll use scoring methods to verify your identity. A record of this search will be kept and may be used to help other companies verify your identity. We may also pass information to financial and other organisations involved in money laundering and fraud prevention to protect ourselves and our customers from theft and fraud. If you give us false or inaccurate information and we suspect fraud, we ll record this and share this information with other organisations. We may monitor and record phone calls and retain these for the purposes of training and quality assurance and to ensure that we have an accurate record of your instructions. If you provide us with information about another person, you confirm that they ve appointed you to act for them to consent to the processing of their personal data and that you ve informed them of our identity and the purposes (as set out above) for which their personal data (including sensitive personal data) will be processed. You have the right to ask for a copy of the information that we hold on you, for which we re entitled to charge a small fee. You can ask us to correct any inaccuracies in your information. If you have any questions about how we ll use your personal information, please write to us at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. Page 8 of 13
9 9 Access to medical reports We may need to obtain a medical report from your current GP or specialist, or from a doctor you ve seen in the past. You have specific rights in relation to medical reports, which are covered in the Access to Medical Reports Act 1988 (also the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991, and the Access to Health Records and Reports Act 1993 (Isle of Man)). Before we ask for such a report, we need your consent, which you can give by signing the declaration in section 9. You can choose not to give your consent, but then we may not be able to continue with your application. This doesn t prevent you from applying to other insurance companies for insurance. We ll let you know if we ask for a report. Under the above Acts, you can choose to see your medical report before it is sent to us. You ll then have 21 days to make arrangements with your doctor to see it. You should indicate below whether you want to see your report. If you don t want to see the report now, you can still contact your doctor later and tell them that you do in fact want to see it. As long as it hasn t already been sent to us, you ll still have 21 days from the time you contact your doctor to make arrangements to see it. If the report has already been sent to us, you re entitled to see a copy of the report at any time during the six months following the date the report was sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date. If you say that you do want to see the report, then it won t be sent to us until: either you ve seen the report or 21 days have passed since we requested the report and the doctor hasn t heard from you. If you see the report, you can withdraw your consent for the doctor showing it to us, or you can ask the doctor to change it if you disagree with it. If the doctor refuses to change it, you can insist that they attach a statement of your views to the report. A doctor may refuse to let you see your report if they feel that seeing it will cause physical or mental harm to you or others. Note: Your doctor is entitled to charge you for supplying you with a copy of the report. The medical report your doctor fills in asks about the following: Your current health any care, medication or treatment you re currently receiving the results of referrals or tests you re waiting for. Any time off work in the last three years Your past health details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultation 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) diseases 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, or 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 in the last two years, urinalyses (tests on urine), x-rays or other investigations Any blood pressure readings in the last three years Any history of disease among your parents or brothers or sisters that you ve told your doctor about. We have asked your doctor not to reveal information about: negative tests for Human Immunodeficiency Virus (HIV), Hepatitis B or C Any sexually-transmitted diseases unless there could be long-term effects on your health, or Predictive genetic test results unless there is a favourable test result which shows that you ve not inherited a condition your family suffers from. The information you and your doctor provide about your health may result in us: Refusing to provide insurance Increasing premiums above standard rates, or Setting premiums at standard rates. If you have any questions about your rights or questions relating to the process of getting, assessing or storing medical information, please write to us at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. Page 9 of 13
10 9 Declaration Access to medical reports declaration Person 1 and Person 2 should always complete these boxes. Name Person 1 Person 2 Postcode Please only tick this box if you DO want to see your medical report before it s sent to Royal London. Enter plan number here if your financial adviser is sending this page to Royal London as an AMRA declaration for an application submitted online. I ve read the statement in section 9 notifying me of my rights under the Access to Medical Reports (AMRA) legislation, and consent to my doctor providing medical reports to Royal London so that they can deal with my application for a protection plan. Yes I DO want to see my medical report. I understand that it won t be sent to Royal London until I ve seen it, and that they won t be able to make a decision on my application until then. I ve read the statement in section 9 notifying me of my rights under the Access to Medical Reports (AMRA) legislation, and consent to my doctor providing medical reports to Royal London so that they can deal with my application for a protection plan. Yes I DO want to see my medical report. I understand that it won t be sent to Royal London until I ve seen it, and that they won t be able to make a decision on my application until then. Declaration and consent Signature Person 1 Person 2 Date D D M M Y Y Y Y D D M M Y Y Y Y Page 10 of 13
11 10 Direct Debit details Please complete and return this form to Royal London, 1 Thistle Street, Edinburgh EH2 1DG You must complete this form if: The person, or people, paying for the plan are not the applicant(s). More than one signature is required to authorise payments for the plan. So that we can identify the plan when you return this form, please give us the full name of the person or people covered. Name Person 1 Person 2 Postcode Date of birth D D M M Y Y Y Y D D M M Y Y Y Y Application number The Royal London Mutual Insurance Society Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. The firm is on the Financial Services Register, registration number It provides life assurance and pensions. Registered in England and Wales number Registered office: 55 Gracechurch Street, London, EC3V 0RL. Royal London Marketing Limited is authorised and regulated by the Financial Conduct Authority and introduces Royal London s customers to other insurance companies. The firm is on the Financial Services Register, registration number Registered in England and Wales number Registered office: 55 Gracechurch Street, London, EC3V 0RL Page 11 of 13
12 Page 12 of 13
13 Royal London 1 Thistle Street, Edinburgh EH2 1DG royallondon.com All literature about products that carry the Royal London brand is available in large print format on request to the Marketing Department at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. All of our printed products are produced on stock which is from FSC certified forests. The Royal London Mutual Insurance Society Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. The firm is on the Financial Services Register, registration number It provides life assurance and pensions. Registered in England and Wales number Registered office: 55 Gracechurch Street, London, EC3V 0RL. Royal London Marketing Limited is authorised and regulated by the Financial Conduct Authority and introduces Royal London s customers to other insurance companies. The firm is on the Financial Services Register, registration number Registered in England and Wales number Registered office: 55 Gracechurch Street, London, EC3V 0RL. November 2015
PERSONAL ACCIDENT AND ILLNESS/INCOME PROTECTION CLAIM FORM
PERSONAL ACCIDENT AND ILLNESS/INCOME PROTECTION CLAIM FORM Effective 01.10.2008 www.compassuw.com How to complete this claim form Please read carefully Please make sure all sections are fully completed
More informationCanada Life Group Income Protection
Claim Form Important When an employee is absent from work due to an illness, we understand the value of an efficient and timely decision on a claim. We also aim to make the claim process as straightforward
More informationPlease read this section carefully before completing this application form.
Workplace pensions 14DOH DECLARATION OF HEALTH Application form 1 Important information Please read this section carefully before completing this application form. Please use BLOCK CAPITALS and black ink
More informationA7. Please ensure a copy of the quotation is enclosed with this application. Copy quote enclosed (tick box)
Application for Executive Income Protection using Tele-Underwriting service Please return this form to Unum, Milton Court, Dorking, Surrey, RH4 3LZ. Cheques should be made payable to Unum. Section 1 -
More informationHow To Get A Higher Income Pension Plan
Annuities Application and income payment form A Below Standard Lifetime Allowance Please use black ink and write in CAPITAL LETTERS or tick 4 as appropriate. Any corrections must be initialled. Please
More informationPrivate medical insurance application form.
Private medical insurance application form. Group leaver How to complete this form Please use BLOCK CAPITALS and black ink when completing this form. There are three forms included here. You should only
More informationAdditional contribution application form
14P44 GROUP STAKEHOLDER PENSION PLAN Additional contribution application form You ll need to complete this application form to apply an additional regular contribution and/or single contribution to your
More informationAttending Physician s Report
Attending Physician s Report t for use in the United Kingdom Doctor s name Doctor s address XIM/APR Doctor s fax number Doctor s email Application reference Please return to: Patient Name of Birth Address
More informationSTOCKS & SHARES INDIVIDUAL SAVINGS ACCOUNT
STOCKS & SHARES INDIVIDUAL SAVINGS ACCOUNT Investments 2015/2016 Application Form STOCKS & SHARES INDIVIDUAL SAVINGS ACCOUNT 2015/2016 application form Please keep this page for your records The Direct
More informationPersonal Protection Menu Data capture form (June 2013)
FOR INTERACTIVE QUOTE AND APPLY Personal Protection Menu Data capture form (June 2013) You should only use this form to capture the information you ll need from your client to use our online interactive
More informationPENSIONBUILDER CONTINUATION FORM
PENSIONBUILDER CONTINUATION FORM You should use this form if you have one of the following contracts: Individual Personal Pensionbuilder Company Personal Pensionbuilder Please complete this application
More informationFoundation dentists application form
Foundation dentists application form For all UK applications Important notes: Before completing this application form It is important that you have been given a copy of our key features document and your
More informationPolicy. Conditions. Protection Policy Conditions. Protection
Protection Policy Conditions Policy Conditions Protection IMPORTANT Please keep these documents safely The utmost care should be taken of this policy as duplicates of lost policies can not generally be
More informationApplication form for Financial Protection Plan
Application form for Financial Protection Plan Campaign code Policy number (if known) When you apply for insurance of any kind, it is most important that you give the insurance company all the material
More informationCONDITIONS Over 50s Life Cover
TERMS AND CONDITIONS Over 50s Life Cover 1 TERMS AND CONDITIONS: OVER 50S LIFE COVER PROVIDED BY THE ROYAL LONDON MUTUAL INSURANCE SOCIETY LIMITED ( ROYAL LONDON ) This booklet contains the Terms and Conditions
More informationShepherds Simple Income Protection Plan
Mutual Solutions. Mutual Benefits. Your Future. Shepherds Simple Income Protection Plan Application Form PLEASE COMPLETE IN BLOCK CAPITALS AND ANSWER ALL QUESTIONS A Life Assured details 1 Have you previously
More informationBUSINESS FINANCIAL QUESTIONNAIRE (NOVEMBER 2015)
Plan number BUSINESS FINANCIAL QUESTIONNAIRE (NOVEMBER 2015) Important Note: Please answer all of the questions on this form honestly and in full. If you miss any information out, or give us misleading
More informationTERMS OF BUSINESS FROM ROYAL LONDON INCORPORATING OUR TRADING NAME SCOTTISH PROVIDENT
For advisors only TERMS OF BUSINESS FROM ROYAL LONDON INCORPORATING OUR TRADING NAME SCOTTISH PROVIDENT Protection DOING BUSINESS TOGETHER 1. Our terms of business set out the conditions upon which we
More informationLife Cover: Application and Amendment Form. Teachers AVC Facility
Life Cover: Application and Amendment Form Teachers AVC Facility Name of scheme Scheme reference number (Please refer to your Teacher's AVC benefit statement if you have one) Part 1 Personal details I
More informationLife Cover: Application and amendment form
Universities AVC Facility Life Cover: Application and amendment form Please use black ink and write in CAPITAL LETTERS or tick as appropriate. Any corrections must be initialled. Please do not use correction
More informationShepherds Simple Income Protection Plan
Company name: Adviser name: Advised sale: Please choose delivery option: Original policy emailed to client plus copy to adviser Original policy plus copy emailed to adviser only Shepherds Simple Income
More informationA7. Please ensure a copy of the quotation is enclosed with this application. Copy quote enclosed (tick box)
Application for Executive Income Protection Please return this form to Unum, Milton Court, Dorking, Surrey RH4 3LZ. Cheques should be made payable to Unum. Section 1 - to be completed by the Intermediary
More informationDISCOUNTED GIFT & INCOME TRUST UNDERWRITING/HEALTH QUESTIONNAIRE
DISCOUNTED GIFT & INCOME TRUST UNDERWRITING/HEALTH QUESTIONNAIRE 1. TYPE OF UNDERWRITING REQUIRED Please tick one box only A. Full advance underwriting required (you must now complete this form) If the
More informationINSTANT SAVER 2 ACCOUNT
INSTANT SAVER 2 ACCOUNT Provided by Scottish Widows Bank APPLICATION FORM This form is only for the use of personal customers. Account Number (For office use only) Please complete this form in BLOCK CAPITALS
More informationPRIVATE MEDICAL INSURANCE
PERSONAL HEALTHCARE APPLICATION CONTINUED PERSONAL MEDICAL EXCLUSIONS (CPME/SWITCH) PRIVATE MEDICAL INSURANCE To be used for new plans commencing from 01 July 2015. To apply for VitalityHealth membership
More informationAPPLICATION FORM. / / / PENSION ANNUITY. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL
PENSION ANNUITY APPLICATION FORM. Once you ve completed this form, please return it to: Legal & General Annuities PO Box 809 Cardiff CF24 0YL We will already have sent you a quote(s), illustrating the
More informationDeclaration of Health
IMPORTANT INFORMATION This information may be downloaded to your PC in whole or in part provided that any reproduction or copy, or any derivative, is true to the original, and it is EITHER used for personal
More informationBack to day 1 or Excess period Mortgage Payment Protection Insurance
Back to day 1 or Excess period Mortgage Payment Protection Insurance Including an Exclusive LOYALTY Payment Holiday Bonus and "Back-to-Work" assistance Package Valid from 01.05.2006 mortgagerewards 1.
More informationPersonal Accident Claim Form
Personal Accident Claim Form Claimant Details Title Full Name Date of Birth Occupation Usual Country of Domicile Claimant Address: Contact Details Postcode: Daytime Telephone: Email Address: Wherever possible
More informationDIRECT TRANSFER ACCOUNT 2
DIRECT TRANSFER ACCOUNT 2 Provided by Scottish Widows Bank APPLICATION FORM Account Number (For office use only) Please complete this form in BLOCK CAPITALS and in ink. APPLICATION CHECKLIST In order for
More informationINDIVIDUAL APPLICATION FORM LIFE COVER 45PLUS
INDIVIDUAL APPLICATION FORM LIFE COVER 45PLUS STERLING LIFE LIMITED IS AUTHORISED AND REGULATED BY THE PRUDENTIAL REGULATION AUTHORITY AND REGULATED BY THE FINANCIAL CONDUCT AUTHORITY AND THE PRUDENTIAL
More informationINTRODUCTORY OFFER PAYMENT FREE FOR THE FIRST 3 MONTHS! Valid from 1.7.2010. Allison & Partners Insurance Services
Income Protection Insurance INTRODUCTORY OFFER PAYMENT FREE FOR THE FIRST 3 MONTHS! Valid from 1.7.2010 Allison & Partners Insurance Services Please read the following information carefully before the
More informationYour Guide to Insurance for Life Insurance
Your Guide to Insurance for Life Insurance LIFE INSURANCE About this Guide This guide provides important information from both Barclays and Aviva (the insurance provider of this policy), and is for your
More informationFact find template BUSINESS PROTECTION. Contact details. Protection Business Menu
BUSINESS PROTECTION Fact find template This fact find template will help you to understand more about your client s business and provide an opportunity for you to ask them where the money would come from
More informationInitial Charge waived ISA. Class R GBP Application forms 2015/2016 Terms and conditions
Initial Charge waived 0% ISA Class R GBP Application forms 2015/2016 Terms and conditions ISA terms and conditions Definitions Account Account holding your Investments in an ISA. Additional Permitted Subscription
More informationNON-PERSONAL SAVINGS ACCOUNT
NON-PERSONAL SAVINGS ACCOUNT DETAILS AMENDMENT FORM Send your completed form to: Scottish Widows Bank plc, PO Box 12757, 67 Morrison Street, Edinburgh EH3 8YJ. Telephone: 0345 845 0829. This form should
More informationLife Assurance. For Broker Use Only. Application Form. Please complete in all cases. Email address for communication: Contact details
ssurance Application Form For Broker Use Only Please complete in all cases Email address for communication: Contact details esp policy number if applicable Straight to policy (To avail of Free Cover if
More informationTransfer application form
For customers Guaranteed Pension Annuity (tax-free cash) Transfer application form Illustration number Agent number / Agent phone number Agent fax number Agent email address Page 1 of 12 Application checklist
More informationPERSONAL INCOME PROTECTION APPLICATION
PROTECTION PERSONAL INCOME PROTECTION APPLICATION Adviser s Name: Agency No.: Please tick (3) where appropriate Please ensure that all questions are answered to prevent any delay in the assessment of your
More informationGroup Personal Pension
Application Form (For employed or self-employed individuals) Who this form is for When we refer to Standard Life we mean Standard Life Assurance Limited This form is for employees, or self-employed individuals
More informationOUR PERSONAL MENU PLAN
KEY FACTS OF OUR PERSONAL MENU PLAN Important information you should read Protection Personal Menu WHAT S INSIDE See if our plan is right for you 3 The aims of our plan 3 Your commitment 4 The risks 4
More informationMORE CHOICE MORE FREEDOM
LOOK FORWARD TO MORE CHOICE MORE FREEDOM A guide to Income Release Pension Portfolio royallondon.com WELCOME TO ROYAL LONDON We re a mutual organisation and, unlike a PLC, we don t have any shareholders
More informationIncome Protection. Application Form. Income One. Pure Protection. Bills & Things
Income Protection Application Form Income One Pure Protection Bills & Things (For completion by Intermediary) Exeter Family Friendly unique reference number (if known) FCA Number Adviser Name Email Company
More informationKEEPING YOUR BUSINESS ON COURSE. Helping you protect your business. Protection Business Menu
KEEPING YOUR BUSINESS ON COURSE Helping you protect your business Protection Business Menu WHAT S INSIDE As a business owner you know what you need to make your business a success. Suitable premises, machinery
More informationUse a separate piece of paper if you need any more space for any of your answers but please sign and date it.
Alteration Form 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
More informationLAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME APPLICATION FORM
LAW SOCIETY OF IRELAND INCOME PROTECTION SCHEME APPLICATION FORM SECTION 1 PERSONAL DETAILS Mr. Mrs. Ms. Date of birth: First Name: Surname: Address: Contact Numbers: Home Work Mobile Email SECTION 2 MEMBERSHIP
More informationPRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE AND CORPORATE HEALTHCARE
MORATORIUM APPLICATION FORM PRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE AND CORPORATE HEALTHCARE For employees (new business and mid-term joiners) and addition of dependants to apply for VitalityHealth
More informationANZ Superannuation Savings Account Life Insurance Application Form
12 March 2014 Customer Services Phone 13 38 63 Fax 02 9234 6668 Email customer@onepath.com.au Website anz.com Note: Please ensure you complete all details on this form. Any missing details will delay your
More informationSolutions Application Form
Solutions Application Form group size appropriate to your policy: 2-99 group members 100-249 group members read through the following before completing this application in BLOCK CAPITALS and in black ink.
More informationApplication for Private Medical Insurance Policyholders switching to Healthier Solutions
For office use only SR. Application for Private Medical Insurance Policyholders switching to Healthier Solutions Important: please read this section and then complete the application in BLOCK CAPITALS
More informationEMPLOYEE APPLICATION FORM LOCAL AUTHORITY AVC FOR OFFICE USE ONLY. Agency Number. Referral Type. Introducer Code. Vantive Lead ID
EMPLOYEE APPLICATION FORM LOCAL AUTHORITY AVC Agency Number FOR OFFICE USE ONLY Referral Type Vantive Lead ID Introducer Code (if different from above) Campaign Code SB Code S B Branch Sort Code Please
More informationHow To Buy An Annuity From Luv
No ID or age evidence required PENSION Pension Annuity Annuity Application Form Before you complete this form n n Please read the key features document, as it contains important information about your
More information3 YEAR FIXED TERM DEPOSIT ACCOUNT
3 YEAR FIXED TERM DEPOSIT ACCOUNT Provided by Scottish Widows Bank APPLICATION FORM (For office use only) Issue Interest Rate Account Number APPLICATION CHECKLIST In order for us to open your account,
More informationLANCASHIRE POLICE FEDERATION CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM
LANCASHIRE POLICE FEDERATION CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM This scheme is open to any Police Staff or Serving Officer who is also a member of the Lancashire Police Group Insurance
More informationOnline Accounts. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney. Title: Mr, Mrs, Ms, Miss Other (please specify) Surname
Online Accounts Power of Attorney application form Please read these notes before you fill in this form The account will be operated strictly in accordance with the instructions confirmed within the Power
More informationNORTH WALES POLICE FEDERATION GROUP LIFE CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM
NORTH WALES POLICE FEDERATION GROUP LIFE CRITICAL ILLNESS INSURANCE SCHEME APPLICATION FORM This scheme is open to any Police Staff or Serving Officer who is also a member of the North Wales Police Federation
More informationAccident, Sickness & Critical Illness Claim Form
Republic of Ireland Accident, Sickness & Critical Illness Claim Form Information Before you return your claim form, please ensure that you have me the required waiting period: Waiting period (after initial
More informationThis document contains important information about the Lifestyle Plus Protection plan and you should read it along with your quote.
Key facts of the Lifestyle Plus Protection plan (October 2013) This document contains important information about the Lifestyle Plus Protection plan and you should read it along with your quote. This document
More informationRelevant Life Policy Trust and Nomination Forms
Relevant Life Policy Trust and Nomination Forms Use these forms if an employer owns the plan and they want to provide life cover for one of their employees outside of a registered group life scheme. Part
More informationKEY FEATURES OF PENSION PORTFOLIO SELF INVESTED PERSONAL PENSION (SIPP)
KEY FEATURES OF PENSION PORTFOLIO SELF INVESTED PERSONAL PENSION (SIPP) The Financial Conduct Authority is a financial services regulator. It requires us, Royal London, to give you this important information
More informationIt is very important that you tell us if there is a change to any of the following:
Pensions Health questionnaire Please use black ink and write in CAPITAL LETTERS or tick 4 as appropriate. About this form Please use BLOCK CAPITALS and tick or complete answers as appropriate. Please take
More informationLife Insurance Plans Application Forms
You can either complete this form here on screen or print it off and complete it by hand. Either way you will need to print it off, sign it and physically post it to us through Despatch or via Royal Mail.
More informationThis form consists of 3 separate sections. Please read each section carefully.
32A28 CHANGE OF INVESTMENT Application form You or your financial adviser can alter your existing investment choice at any time on our website royallondon.com, if you/they have the required permissions.
More informationThis document contains important information about the Lifestyle Protection plan and you should read this along with your quote.
Key facts of the Lifestyle Protection plan July 2014 This document contains important information about the Lifestyle Protection plan and you should read this along with your quote. This document doesn
More informationPension Trader Account application
Pension Trader Account application This is an application form to open a Pension Trader Account. Please read this application form in conjunction with your Barclays Stockbrokers Terms of Use and the Terms
More informationContents 1 The purpose of a trust 2 The key people involved in a trust 3 Choosing which trust form to use 5 Deciding how to set up the trust 8 Your
Our guide to trusts Contents 1 The purpose of a trust 2 The key people involved in a trust 3 Choosing which trust form to use 5 Deciding how to set up the trust 8 Your questions answered 13 Appendix 1
More informationKEY FEATURES OF RELEVANT LIFE COVER SCOTTISH WIDOWS PROTECT. Important information you need to read
KEY FEATURES OF RELEVANT LIFE COVER SCOTTISH WIDOWS PROTECT Important information you need to read THE FINANCIAL CONDUCT AUTHORITY IS A FINANCIAL SERVICES REGULATOR. IT REQUIRES US, SCOTTISH WIDOWS, TO
More informationFlexible Life Plan Personal Protection Application
To be used for Policy Applications for: Flexible Life Plan Personal Protection Application Are you an existing Canada Life International Limited or CLI Institutional Limited client? Reference number(s)
More informationBupa Schools Scheme Looking after what s most important
Provided by Bupa Schls Scheme Lking after what s most important bupa.co.uk/schlscheme The subscription rate is 67.50 per child each term and applies for membership year 1 September 2015 to 31 August 2016.
More informationData Capture Form. Self Assurance. IMPORTANT: What product are you applying for? Please tick ONE box. FOR USE WITH WEBCENTRE & PORTAL APPLICATIONS
Self Assurance Data Capture Form FOR USE WITH WEBCENTRE & PORTAL APPLICATIONS FOR INTERMEDIARY USE ONLY THIS IS NOT A PROPOSAL FORM IMPORTANT: What product are you applying for? Please tick ONE box. Self
More informationFTSE 100 Tracker Fund ISA Application Provided by RBS Collective Investment Funds Ltd
FTSE 100 Tracker Fund ISA Application Provided by RBS Collective Investment Funds Ltd p Your information For details of how we and others will use your information and how to give your consent, please
More informationLife Cover and Income Protection Schemes
Life Cover and Income Protection Schemes Application form Special offer for IMO Members Group PHI and Life Cover - reduced medical questions Your commitment to provide honest and complete information to
More informationYour name: Name of your business: Your business address:
For mortgage intermediary use only please complete IN FULL Your NBS introducer code: Your name: Name of your business: Commercial mortgage application for a Company Please fill in every answer using block
More informationCONSENT TO LET APPLICATION FORM
CONSENT TO LET APPLICATION FORM To allow us to consider your request please send us the fully completed consent to let application form. IMPORTANT INFORMATION If consent is granted you will be charged
More informationCanRetire. Application new plan(s) (for single contributions and transfers only) Pension Investment Plan. Flexible Drawdown Plan
CanRetire Application new plan(s) (for single contributions and transfers only) Please enter the Personal Example reference number for your chosen product choice(s) FTIP Pension Investment Plan Flexible
More informationUltraCare International Schools plan Individual application Moratorium
UltraCare International Schools plan Individual application Moratorium Need help completing this application? Please contact either your advisor or us directly. You can find our contact details on our
More informationPART 2 - DETAILS OF THE CLAIM
Lifeline Plus Group Personal Accident & Travel Insurance Personal Accident and Sickness Claim Form The claimant should complete and sign this form. If the claimant is under 18 years of age, this form should
More informationPRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE WITH HEALTHY BUSINESS DISCOUNT
EMPLOYER APPLICATION FORM PRIVATE MEDICAL INSURANCE BUSINESS HEALTHCARE WITH HEALTHY BUSINESS DISCOUNT To be used for new business plans with 2 9 employees who are eligible for a Healthy Business Discount
More informationJust Retirement Fixed Term Annuity Application Form
Just Retirement Fixed Term Annuity Application Form You should make sure you ve read the Key Features Document and the Conditions of the Just Retirement Fixed Term Annuity before you apply. About this
More informationOUR ANNUAL CHECK-UP. Critical Illness Claims Statistics 2014. Protection
OUR ANNUAL CHECK-UP Protection Critical Illness Statistics 21 WE RE IN BUSINESS TO PAY CLAIMS In an industry like ours, claims statistics are important. They help to reassure you that if your clients ever
More informationd d mm y y If the injury was as a result of criminal assault or a Road Traffic Accident, was the accident reported to the police?
Personal Accident Claim Form This form has been designed to help you provide all the information we need to process your claim quickly. Failure to complete this form correctly may delay your claim. We
More informationInvestment Funds ISA Application Form
Investment Funds ISA Application Form Please select one of the following: Lump sum Regular saver investment Combined lump sum and regular saver investment Before completing this application form please
More informationAMP Firstcare Term Life Insurance
AMP Firstcare Term Life Insurance Customer Information Brochure A simple and convenient way to protect yourself and your family s future Issue 7d Issue 1 February 2002. Expires 31 December 2002. You should
More information% of time working at heights % What is the average height you work at?
Relevant for Income Protection cases only: 18 Do any of the following form an essential part of your work? a manual work YES NO % of time at Manual work % b Driving YES NO % of time Driving % Average weekly
More informationOnline Accounts. Power of Attorney application form. Personal details. Donor. 1st Attorney. 3rd Attorney. 2nd Attorney
Online Accounts Power of Attorney application form Please read these notes before you fill in this form The account will be operated strictly in accordance with the instructions confirmed within the Power
More informationThis Trust form is designed for use to hold the lump sum death benefits payable under the following plan types in trust:
GGA1568 FLEXIBLE TRUST FORM This Trust form is designed for use to hold the lump sum death benefits payable under the following plan types in trust: Individual Plan issued in connection with your past
More informationPension Trader Account for SIPP application
Pension Trader Account for SIPP application This is an application form to open a Pension Trader Account for SIPP. Please read this application form in conjunction with your Pension Trader Account for
More informationPost Office Life Insurance
Post Office Life Insurance Key Information Pack Contents 1. Information Disclosure Document Pg 2 2. Data Protection statement Pg 3 3. Customer Due Diligence Prevention of Money Laundering statement Pg
More informationAmendments to your Savings Account
Page 1 of 6 Isle of Man Savings Amendments to your Savings Account Please fill in the form using BLOCK CAPITALS and black ink. Tick any boxes which apply. Santander is able to provide literature in alternative
More informationSelf Assurance Term Personal. Self Assurance Mortgage. Self Assurance Term Business. Changes of circumstances. Important information
Self Assurance Application Form For intermediary use only Please tick this box if you have made a personal recommendation to your customer to buy this plan. Please tick this box if commission details are
More informationLOAN APPLICATION FORM
ERVER\Cumis\CumisDocuments ver\cumis\cumisreports\customreports FalseFalse FAS Credit Union False Ltd FalseTrue FAS Credit Union Ltd 27-33 Upper Baggot Street, Dublin 4 Phone : 01-6070516 Fa : 01-6070624
More informationPrivate medical insurance claim form
Private medical insurance claim form *113N1A3B* Please make sure that you read the following before completing the claim form: n Confirmation of cover will be provided when we have made a decision on your
More informationPASSING ON YOUR PENSION. A guide to death benefits from income drawdown. Retirement Solutions
PASSING ON YOUR PENSION A guide to death benefits from income drawdown Retirement Solutions It s now easier than ever to pass any remaining money in your pension to the people you love when you die. New
More informationpension income plus pension income plus annuity Annuity
No ID or age evidence required pension income plus pension income plus annuity Annuity Application Form For Financial Adviser completion only Adviser Financial Services Register number Adviser email address
More informationTenants and Leaseholders Home Contents Insurance Scheme Application Form
Tenants and Leaseholders Home Contents Insurance Scheme Application Form (Subject to the terms, exclusions and conditions of the policy, a specimen of which is available on request). Before you fill in
More informationIncome Continuance Plan For staff members of the University of Limerick (UL)
Income Continuance Plan For staff members of the University of Limerick (UL) Standard application form Eligibility - please note that members must be under age 65 To be eligible to apply for membership
More informationAIG Life. Whole of Life Insurance. Key Facts
AIG Life Whole of Life Insurance Key Facts Contents Page Welcome to AIG 3 Section A: About Whole of Life Insurance A1 What is Whole of Life Insurance? 4 A2 Whole of Life Insurance aims 4 A3 How does Whole
More informationAIG Life. YourLife Plan Income Protection. Key Facts
AIG Life YourLife Plan Income Protection Key Facts Contents Page Welcome to AIG 3 Section A: About Income Protection A1 What is Income Protection? 4 A2 Income Protection aims 4 A3 How does Income Protection
More informationKEY FEATURES. Helping you to keep your lifestyle safe when your income isn t.
LIFESTYLE COVER INSURANCE LIFESTYLE COVER INSURANCE POLICY SUMMARY 1 KEY FEATURES. Helping you to keep your lifestyle safe when your income isn t. USEFUL PHONE NUMBERS. GENERAL ENQUIRIES: 0370 900 3119
More informationWoolworths NSW Member Income Protection Form
Woolworths NSW Member Income Protection Form Complete this form if you want to apply for or increase your Income Protection insurance cover. Income Protection insurance cover, also known as salary continuance
More information