DATA CAPTURE FORM LIFE CHOICE

Transcription

1 DATA CAPTURE FORM LIFE CHOICE Please tick ( ) one box only. Life Choice - Home Life Choice - You and Family Life Choice - Assets Note: If you wish to apply for two or more policies a separate Declaration Form must be used for each product. 1. Person(s) to be covered First Person to be covered Second Person to be covered Title: Mr Mrs Ms Other Mr Mrs Ms Other Surname: First Name: Sex: Male Female Male Female Date of Birth: Marital Status: Married Single Divorced Married Single Divorced Widowed Separated Partner Widowed Separated Partner Gross Annual Earned Income: Address: Occupation: Telephone*: Home: Work: Mobile: Consent to seek information** from other insurers: Yes No Yes No * By providing telephone number(s) you are agreeing that New Ireland or a duly authorised agent of New Ireland may contact you by phone if it considers it necessary to obtain further medical or other information relating to your application. ** Information means medical and other details given to an insurer by me or any doctor in connection with a life insurance application on my life. 2. Policy Owner(s) (Complete only if different from above) First Policy owner Second Policy owner Title: Mr Mrs Ms Other Mr Mrs Ms Other Surname: First Name: Address: Page 1 of 8

2 3. Contract Details Preferred Policy Start As soon as possible To be advised Only dates from 1 to 28, inclusive, are permitted. Reason for Cover Is the relationship between the policy owner(s) and (s) to be covered husband and wife Yes No or joint mortgagees? If No please give the reason for the policy: Is this application to replace an existing New Ireland policy? Yes No If Yes, please provide policy number(s): Note: It is not possible to cancel assigned policies without the prior written consent of the assignee. 4. Cover Details: Life Choice - Home (Mortgage Protection) (Single or Joint Life) Payment Method Monthly - Direct Debit Quarterly - Direct Debit Half Yearly - Direct Debit Yearly - Direct Debit Yearly - Cheque Half Yearly - Cheque Term of Cover years Benefits Lump Sum on Death Accelerated Specified Illness (only available with Lump Sum on Death) e e Medical Free Conversion Yes Please select additional benefits required: First Person Second Person Surgery Payment Yes Yes (only available with Accelerated Specified Illness) Accident Payment e per week e per week Hospitalisation Payment e per day e per day Broken Bones Payment Yes Yes 5. Cover Details: Life Choice - You and Family (Term Assurance) (Single or Dual Life) Payment Method Monthly - Direct Debit Quarterly - Direct Debit Half Yearly - Direct Debit Yearly - Direct Debit Yearly - Cheque Half Yearly - Cheque Increasing Benefits (Benefits and Premiums increasing at 3% p.a.) Yes Page 2 of 8

3 5. Cover Details: Life Choice - You and Family (Term Assurance) (contd.) (Single or Dual Life) Cover Please select at least one of Lump Sum on Death, Standalone Specified Illness or Income on Death: First Person Second Person Lump Sum on Death Specified Illness e e e e Accelerated (only available with Lump Sum on Death) Additional Standalone Accelerated (only available with Lump Sum on Death) Additional Standalone Medical Free Conversion Yes Term of Cover years Income on Death e per month e per month Term of Cover years Please select additional benefits required: (Term will default to the longest of the Lump Sum on Death, Standalone Specified Illness and/or Income on Death) Whole of Life Continuation e e (May only be selected if main benefit term exceeds 10 years) Surgery Payment Yes Yes (only available with Specified Illness) Accident Payment e per week e per week Hospitalisation Payment e per day e per day Broken Bones Payment Yes Yes 6. Cover Details: Life Choice - Assets (Business Protection) (Single or Joint Life) Payment Method Monthly - Direct Debit Quarterly - Direct Debit Half Yearly - Direct Debit Yearly - Direct Debit Yearly - Cheque Half Yearly - Cheque Term of Cover years Increasing Benefits (Benefits and Premiums increasing at 3% p.a.) Yes Benefits Lump Sum on Death Specified Illness e e Accelerated* Additional Standalone *only available with Lump Sum on Death Medical Free Conversion Yes Page 3 of 8

4 7. Underwriting Method How are you providing underwriting information for this application? Tele-interview Enter Online Tele-interview To speed up the processing of your application we strongly recommend you arrange a Tele-interview prior to submiting the application to us as this will avoid unnecessary delays in processing your application. This Tele-interview will be recorded. You may contact our Tele-interview provider on freephone to arrange a suitable time for your Tele-Interview. You will be given a reference number to record in the field below: First Person Second Person Tele-interview reference number: Please ensure you have provided at least one telephone number in Section 1. If you are not in a position to arrange a Tele-interview before the application is submitted online we will pass on your al details to our Tele-interview provider who will then contact you to arrange a suitable appointment. Please note that this will likely result in your application taking longer to process. First Person Second Person Have you smoked cigarettes, cigars or pipe tobacco in the last 12 months? Yes No Yes No What is your occupation? Simultaneous applications If you are submitting more than one application for any life, it is only necessary to provide Underwriting Information on that life once. Would you like us to use the Underwriting Information provided for another Yes No Yes No application on the to be covered submitted recently (i.e. within 48 hours)? If yes please enter application number/tele-interview reference number (as appropriate) How many applications are you submitting at this time (including this one)? 8. Doctor/Clinic Details Please state the name(s) and address(es) of your doctor and any other doctor you have attended in the last 12 months. Current: First Person Current: Second Person Other: Other: 9. Occupation Information (complete only for non Tele-Interview applications) First Person Second Person What is your occupation? Is your occupation 100% administration/supervisory/managerial? Yes No Yes No Does your work involve any manual duties? Yes No Yes No If yes, give details including % of working week on manual work Does your occupation involve work at sea, work underground or use of explosives? Yes No Yes No If yes, give details including % of working week spent in any of these situations Do you work at heights above 50 feet? Yes No Yes No If yes, what % of your time do you spend working above this height? % % Page 4 of 8

5 10. Risk Assessment (complete only for non Tele-Interview applications) First Person Second Person 1. a. Have you smoked cigarettes, cigars, or pipe tobacco in the last 12 months? Yes No Yes No b. If Yes, how much do you smoke each day or if you have stopped smoking in the last 12 months how much did you smoke each day? Cigarettes per day Cigarettes per day Cigars per week Cigars per week Pipe tobacco per day Pipe tobacco per day 2. How much alcohol do you drink each week? Unit guide: Pint beer = 2.0 units Bottle beer = 1.5 units Measure spirits = 1.0 units units per week units per week Bottle wine = 7.0 units Glass wine = 1.0 units. 3. a. What is your height? ft ins or cm ft ins or cm b. What is your weight? st lbs or kg st lbs or kg Please provide details about any disclosure(s) below such as: exact condition, when diagnosed, tests / investigations results, treatment and any current medication and date of last review with your GP / specialist. Some details about your medical history: Yes No Yes No 4. Do you currently have or have you ever had any of the following: a. heart attack, angina, heart bypass surgery, heart valve disorder, heart murmur, angioplasty, heart related chest pain or any other heart disease or disorder? b. problems with the aorta, poor circulation in the legs or problems with the arteries excluding cholesterol? c. cancer, malignant tumour, leukaemia, Hodgkin s disease, Non Hodgkin s disease, lymphoma or any brain or spinal tumour? d. schizophrenia, bipolar affective disorder / manic depression, psychosis, paranoia or mania? e. stroke, TIA or mini stroke, brain haemorrhage, brain or spinal cord injury, coma or amnesia? f. multiple sclerosis, Parkinson s disease, motor neurone disease, cerebral palsy, muscular dystrophy, Alzheimer s disease, dementia or Huntington s disease? g. paralysis, numbness or tingling in the limbs or face, tremor, temporary loss of muscle power or lack of co-ordination, double / blurred vision or optic neuritis? h. diabetes, sugar in the urine, raised blood sugar, low blood sugar or glucose intolerance? i. hepatitis, cirrhosis of the liver, other liver disorders, pancreatitis, ulcerative colitis, Crohn s disease or removal of part or all of the bowel / colon? 5. Have you ever had treatment or counselling for alcohol excess or misuse or have you ever been advised by a medical practitioner to cease or reduce your alcohol consumption? 6. Have you ever used any recreational drugs such as cannabis, cocaine, heroin, ecstasy, amphetamines, anabolic steroids or non-prescription sedatives? 7. Have you ever tested positive for HIV or are you awaiting the result of an HIV test? 8. Within the last 5 years have you tested positive for, or been treated for, any disease which was transmitted sexually? First Second First Second Page 5 of 8

6 10. Risk Assessment (continued) Please provide details about any disclosure(s) below such as: exact condition, when diagnosed, tests / investigations results, treatment and any current medication and date of last review with your GP / specialist. 9. In the last 5 years have you had, or do you Yes No Yes No currently have any of the following: a. asthma, bronchitis, emphysema or any other lung or breathing disorder? b. high blood pressure, raised cholesterol or low blood pressure? c. depression, stress, anxiety, eating disorders, chronic fatigue syndrome or other nervous or mental disorder? d. cyst, lump, polyp, lesion, growth of any kind, or any mole that has: bled, become painful, changed colour or increased in size? e. epilepsy, seizure, fit, fainting, dizziness, blackouts, severe headaches, migraines, concussion, meningitis or encephalitis? f. back and neck disorders including disc problems, sciatica, whiplash, diseases of the spine, back and neck pain or trapped nerves? g. arthritis, rheumatoid / psoriatic arthritis or any other joint problems? h. disorder of the digestive system or stomach, including reflux, ulcers, hernia, oesophagitis or Coeliac disease? i. thyroid problems, goitre or glandular fever? j. disorder of the eyes that is not corrected by spectacles or contact lenses including: impaired vision, blindness, cataract or glaucoma? k. disorder of the ears, nose or throat including: hearing impairment / deafness, tinnitus or vertigo? l. anaemia, blood clotting disorders, haemophilia, haemochromatosis, thalassaemia or other blood disorders? m. - kidney stone(s), disease or surgery, prostate problems, testicular problems or abnormal urine test results? (males only) - kidney stone(s), disease or surgery or abnormal urine test results? (females only) n. abnormal smear test results, menstrual disorders, hysterectomy, endometriosis, fibroids, ovarian cysts or mammogram which required further investigation? (females only) 10. Have you had any medical investigations, scans or tests within the last 5 years? 11. Are you receiving or awaiting ongoing medical treatment, referral, medical investigation, test results, surgical procedure or intending to seek medical advice or treatment? Concerning your family: 12. a. Have any of your biological parents, brothers or sisters had any of the following medical conditions before age 60: (i) cancer of the breast, ovaries, colon, bowel, rectum, stomach, polyposis of the colon or any other form of cancer? (ii) heart attack, angina, heart by-pass, angioplasty, heart failure, cardiomyopathy, stroke, diabetes, haemochromatosis, high blood pressure or raised cholesterol? First Second First Second Page 6 of 8

7 10. Risk Assessment (continued) (iii) multiple sclerosis, Huntington s disease, polycystic kidney disease, motor neurone disease, muscular dystrophy, Parkinson s or Alzheimer s disease? b. Apart from the conditions listed above, have 2 or more of any of your biological parents, brothers or sisters had the same condition before age 60? c. Other than a genetic test have you undergone or been advised to have any specific tests or investigations as a result of a condition one of your biological parents, brothers or sisters had? First Second Yes No Yes No First Second First Condition (If cancer, specify the part of the body affected first, eg. bowel) (If heart disease, specify exact nature of heart disease) Relative Age at Diagnosis Details of any check-up/screening Second Condition (If cancer, specify the part of the body affected first, eg. bowel) (If heart disease, specify exact nature of heart disease) Relative Age at Diagnosis Details of any check-up/screening First Second First Second About your travel and interests: 13. In the last 10 years, have you spent more than 6 months outside of Ireland, the EU, North America, Japan, Singapore, Hong Kong, New Zealand or Australia? If yes, when, where and for how long? Yes No Yes No 14. In the next 12 months, do you intend to travel or reside for more than 30 days outside of Ireland, the EU, North America, Japan, Singapore, Hong Kong, New Zealand or Australia? If yes, please give country(ies), date, duration and purpose. 15. Do you take part in or intend to take part in any hazardous leisure activities or sports such as scuba diving, motor sports, aviation, water sports, horse riding, martial arts, mountaineering, caving or winter / ice sports? If yes, please complete the appropriate questionaire. Previous Application(s): 16. Have you ever had an application on your life declined, postponed, accepted at an increased premium or with an exclusion imposed for any death, specified or critical illness or disability benefit? If yes, please give the date and reason for the revised items. Page 7 of 8

8 New Ireland Assurance Company plc., Dawson Street, Dublin 2. T: (01) F: (01) E: W: A Member of Bank of Ireland Group. New Ireland Assurance Company plc is regulated by the Central Bank of Ireland V2/11/10 Page 8 of 8

9 DECLARATION FORM LIFE CHOICE 1. Personal Details Application Number: Product: Life Choice - Assets Life Choice - Home Life Choice - You and Family Note: If you wish to apply for two or more policies a separate Declaration Form must be used for each product. First Person to be covered Second Person to be covered Surname: First Name: Address: Telephone: Note: Only to be completed when different from above information. First Policy Owner Surname: Second Policy Owner First Name: Address: Telephone*: Home: Work: Mobile: Consent to seek information** from other insurers: Yes No Yes No * By providing telephone number(s) you are agreeing that New Ireland or a duly authorised agent of New Ireland may contact you by phone if it considers it necessary to obtain further medical or other information relating to your application. ** Information means medical and other details given to an insurer by me or any doctor in connection with a life insurance application on my life. 2. To be completed by Insurance Intermediary Name: Agency No.: Branch No.: Broker Consultant s Name: Broker Consultant s No.: Adviser 3. Premium Change Do you have a valid reason for manually entering a premium? If yes, please give details. Yes No If Yes, please specify: Reason for Change: Revised Standard Premium: 4. Special Instructions for Policy Issue (Excluding 1% government levy) Please include any special instructions for this application in this box: These instructions will not be used for Underwriting purposes. If you wish to have the original policy documents sent to a third party e.g. solicitor, lending/financial institution, please enter the details here: Third Party Name: Address: Page 1 of 4

10 5. Important Information Before signing this form please read carefully the following notes and the declarations in the Declaration/Data protection consent section. If you do not understand the following information please ask your Financial Adviser for clarification. In addition to the premium a Government Levy (currently 1% of the premium) will be payable on each premium paid. You and your Financial Adviser have chosen to complete a Data Capture Form to capture the information necessary to later complete an online application to New Ireland. The declarations in the Declaration/Data protection consent section of this form and the information recorded in your online application and the information provided in any Tele-interview you complete, will constitute your application to New Ireland. All the information provided by you in the Data Capture Form for later entry in your online application must be true and complete or payment of policy benefits may be affected. Within 10 days of this form being signed we will send you a printed record of all the information recorded in your online application. You will be asked to check all the information in that printed record and to inform New Ireland immediately, in writing, if any of the information in it is not true and complete. If you have not received the printed record within 10 days of the date this form is signed you must contact New Ireland immediately. If you have indicated on your application form that you are willing to do a recorded Tele-interview, a Nurse or an Underwriter may contact you by telephone to ask you for further information in relation to your application. Any such telephone calls will be recorded and will form part of the basis of the proposed contract. Important Notes in relation to Material Facts You are legally obliged to tell us all relevant information (material facts) in answering the online application questions. Material facts are those which an Insurer would regard as likely to influence the assessment and acceptance of an application for insurance. If you are in doubt as to whether certain facts are material, such facts should be disclosed. The policy may be void (there is no cover under the policy) If you do not tell us all material facts If any of the information you provide is not true and complete If you do not tell us of any changes in your medical and/or other information before the policy starts. You may submit answers to any medical questions direct to the Chief Medical Officer, New Ireland Assurance Company plc at Dawson Street, Dublin 2. Please indicate in your letter your name and the application number to which the information applies. All information will be treated in strictest confidence. Any changes to the information in this application or in any Tele-interview you complete before the proposed policy comes into force must be notified in writing to New Ireland. Material Facts Exemption in Relation to Genetic Tests You are not required to disclose any genetic tests you may have had and we will not have regard to any genetic tests which may come into our possession. You are however required to provide us with full details (other than genetic tests) in answer to all the health and lifestyle questions including full medical details about your family history. 6. Declaration of receipt of disclosure information and policy replacement Please ensure you complete this section before signing this proposal for assurance. Declaration under Regulation 6(3) of the Life Assurance (Provision of Information) Regulations, WARNING: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance intermediary. Declaration of Insurer or Intermediary I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the Policy Owner(s), as stated in Section 2 of the Application, have been provided with the information specified in Schedule 1 to those Regulations and that I have advised the client as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction, and of possible financial loss as a result of such replacement. Insurance/Intermediary Declaration of Policy Owner(s). I confirm that I have received in writing the information specified in the above declaration. First Policy Owner Second Policy Owner Page 2 of 4

11 7. Declarations/Data protection consent Please complete irrespective of policy selected. I have read and understand the replies to all the questions in the Data Capture Form and declare that all statements therein all the information recorded in my online application and any statements written at my request or in any questionnaire completed by me or by a medical examiner in connection with this application and signed by me are true and complete and shall be the basis of the proposed contract. I understand that in any questionnaire signed by me and in any Tele-interview I must disclose all material facts. I have read and understand the notes in the Important Information section of this form and understand that if I do not tell you all material facts, the contract with New Ireland could be void. I agree to New Ireland seeking information from any doctor, now or in the event of a claim, who has attended me and I authorise them to give New Ireland such information. I agree that this authority will remain in force after my death. I confirm that if I have answered yes to the Consent to seek information from other insurers question that I am consenting to New Ireland seeking and receiving medical and other details given to an insurer by me or any doctor in connection with a life insurance application on my life. I agree that if I have provided a telephone number New Ireland or a duly authorised agent of New Ireland may contact me in, by phone, if it considers it necessary to obtain further medical or other information relating to my application. I understand that New Ireland reserves the right to test declared non-smokers for Cotinine. I understand that in the event of my application not proceeding, information provided in connection with my application will be retained by New Ireland for a period of six years to facilitate any future application by me and as a protection against non-disclosure of material facts. I confirm that where one or more of the following; Accelerated Specified Illness Benefit, Additional Specified Illness Benefit, Standalone Specified Illness Benefit, Surgery Payment, Accident Payment, Hospitalisation Payment, Broken Bones Payment has been selected that the restrictions, conditions and exclusions that attach to the benefit(s) have been fully and clearly explained to me. I understand that I will receive a printed record of the information recorded in my online application within 10 days and agree to notify New Ireland if I do not receive the printed record within this time. Following receipt of the record I understand that I must ensure the information set out on the record of my application details is true and complete and that I must notify New Ireland of any changes required within 10 working days of receipt of the record. I understand that this policy will not start until New Ireland has accepted me for cover and I have made the first premium payment. I understand that any changes to the statements in this application, any other statements made by me in writing and / or in a Tele-interview before the policy start date must be notified in writing to New Ireland. I understand and consent that New Ireland and its duly authorised agents may hold and use the Information on computer file, in any other dematerialised form or in written hard copy on its own behalf and may use or pass the Information to third parties for regulatory, administration, customer care and service purposes. 1. I agree that New Ireland or a duly authorised agent of New Ireland may contact me in by phone or by letter, Yes No if it considers my financial planning arrangements need to be reviewed or my level of cover needs to be revised. 2. I agree the Information may be held and used by New Ireland for Marketing purposes. Yes No I understand I may write and advise New Ireland to cease to hold and use the Information for Marketing purposes at any time. The Data Controller for the purposes of the Data Protection Acts is New Ireland Assurance Company plc. The al data being collected on this form is for the purposes of processing your application and may be disclosed in accordance with and to other parties as identified and consented to in the paragraphs above. Information means any information including medical and non-medical given by me or on my behalf in connection with this application or any further information which may be given at a later stage either in writing, by , at a meeting or over the telephone. Marketing means direct marketing and cross-selling of the services and/or products provided by New Ireland or arranged by New Ireland with a third party. First Person to be covered Second Person to be covered First Policy Owner (If different from First Person to be covered) Second Policy Owner (If different from Second Person to be covered) Page 3 of 4 8. Direct debit mandate Note: Instructions can only be accepted to charge direct debit to a Current or similar account. To the Manager: Bank Address Name of Account to be debited: Bank Account No.: Bank Sort Code: Policy No.: Originator s Reference Originator s No.: I/We authorise you until further notice in writing to charge to my/our account with you unspecified amounts which may be debited thereto at the instance of New Ireland Assurance Company plc. by direct debit. Signature 1 Signature 2 Comhlucht Na héireann um Árachas c.p.t. New Ireland Assurance Company plc Dawson Street, Dublin 2.

12 New Ireland Assurance Company plc., Dawson Street, Dublin 2. T: (01) F: (01) E: W: A Member of Bank of Ireland Group. New Ireland Assurance Company plc is regulated by the Central Bank of Ireland V2/08/10 Page 4 of 4