Self Assurance. Self Assurance Term Personal. Self Assurance Mortgage. Self Assurance Term Business

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1 Self Assurance Data Capture Form FOR INTERACTIVE QUOTE AND APPLY FOR USE WITH WEBCENTRE & PORTAL APPLICATIONS FOR FINANCIAL ADVISER USE ONLY THIS IS NOT A PROPOSAL FORM IMPORTANT: What product are you applying for? Please tick ONE box. Self Assurance Term Personal Self Assurance Mortgage Self Assurance Term Business You should only use this form to capture information you will need from your client to use our online interactive quote and apply system. We will not accept this form as a replacement for a paper application form. Please note that the data capture form lets you capture a certain amount of information from your client. But if they answer Yes to some of the questions, our interactive system will ask for more information online before you can submit the application to us. This means that your client will need to be present or available by phone when you get to this stage in the application process. If they are not present, you can save the application at any time and go back when they are available. Please note, for your convenience, there is an Access to Medical Reports section at the end of this document. You should ask your client to sign and date this if it is requested at the end of the online application, so you will have a signed copy available to send to us. Please do not send the entire data capture form to us. Please only send the Access to Medical Reports section if requested at the end of the online application. Website registration: To submit business online you must first register for full access to Scottish Provident s Webcentre. Visit then click on the link to register for full access to Scottish Provident s Webcentre and then complete the online registration form. If you would like this information in large print, in braille or on cassette or CD, please call

2 Life or lives to be assured First life Second life Full name Gender Male Female Male Female Date of birth D D M M Y Y Y Y D D M M Y Y Y Y Marital status Single Married/civil partnership Single Married/civil partnership Divorced Separated Divorced Separated Widow(er) Widow(er) Address County Postcode Country of residence UK Guernsey UK Guernsey Jersey Isle of Man Jersey Isle of Man Other Other If Other, please give details If Other, please give details Telephone number Daytime Evening Mobile Daytime Evening Mobile 2 Your client s personal information we, the Royal London Group (including Scottish Provident), may get personal information either from your client directly or, with their consent, from other sources such as their doctor or an identity authentication agency (a reputable third party company which carries out identity checks). The Data protection and identity verification statement included in this form explains how we will use any personal information (including sensitive personal information) we collect. Obtaining medical reports we may ask the life assured for their consent to get medical reports as part of the application or up to 6 months after the cover has started. These will be used to support or verify the answers given to the questions asked in the application process. Before we can ask any doctor that the life assured has consulted to complete a report, we need their permission under the Access to Medical Reports Act The Access to medical reports statement included in this form explains their rights under the act. ABI policy on genetic testing if your client has had a genetic test, they only have to tell us the results if this application, when added together with any cover they have of the same type, is for more than: 500,000 of Death benefit; 300,000 of Critical illness benefit or Death or earlier critical illness benefit; or 30,000 each year of Disability income benefit. However, if they have had a test and the results are in their favour, they can choose whether to tell us the results or not. They must tell us however, if they think they are having treatment for, or are experiencing symptoms of, a genetic condition. The impact of misrepresentation your client must answer all of the questions in this online application honestly and in full. If they are not sure about including any information, then they should include it. If they miss any information out or give Scottish Provident misleading information then this could mean that we will not pay any future claim. Important information before your client takes out their plan, they need to read the important information in each of the following documents. 1. Data protection and identity verification statement 3. Self Assurance product guide 2. Access to medical reports your rights. 4. Self Assurance key features Please read and confirm the following statement: I have provided my client with the documents above and the life assured has read the information on the Access to Medical Reports Act 1988 and has agreed to provide their written consent if asked to do so in the future. Decline Accept

3 Please complete this section if the person applying for the policy is not a life assured. Applicant s details Applicant type Individual Business What is your relationship to or the nature of your interest in the life or lives to be assured? Wife Husband Partner/co-habitant Business partner Employer Other Name If Other, please give details Date of birth D D M M Y Y Y Y Address County Postcode Telephone number Daytime Evening Country of residence (or registration for companies) Mobile UK Guernsey Jersey Isle of Man Other Previous proposals and cover First life Second life Do you have an existing policy or application with Scottish Provident? Please include any previous application which did not go in force or any pending applications. This includes Scottish Provident Self Assurance and Pegasus whole of life products and any plans that are no longer in force or have lapsed. Does the total amount of insurance cover you are applying for, added to the amount you already have, across all insurance companies, exceed: 1,000,000 life cover OR 500,000 critical illness cover? Answer No to this question if you have no existing cover elsewhere and it is only this application that breaches these limits. You need to tell us about: any other policies that are already in force, and any other applications you are making elsewhere which are additional to this application or any other cover you are intending to apply for. You do not need to include death in service benefits in this total. 3

4 Previous proposals and cover (Continued) First life Second life For these types of cover, what is the total number of applications and policies that you have, or have made? What is the cover for? Personal Business Personal Business What is the cover type? Relevant Life Plan Life cover only Life or critical illness cover Critical illness cover only Relevant Life Plan Life cover only Life or critical illness cover Critical illness cover only What is the amount of cover? Will the cover be cancelled when this policy starts? If Yes please go to the question Do you have, or are you making an application for, any other income protection, mortgage payment protection insurance or accident and sickness cover policy? Is the cover in force or a current application? At claim, will the cover be paid as a lump sum or as an income? If Income please answer the question What is the remaining term of the cover? What is the remaining term of the cover? In force Currently applied for In force Currently applied for Lump sum Income Lump sum Income years years What is the reason for the cover? Personal/family protection Mortgage protection Relevant life plan Shareholder Keyperson Keyperson loan Inheritance tax Other Personal/family protection Mortgage protection Relevant life plan Shareholder Keyperson Keyperson loan Inheritance tax Other If Other please give details If you need to tell us about more policies or applications please use the additional information page at the back of this form. 4

5 Previous proposals and cover (Continued) First life Second life Only answer this question if you are applying for Disability income benefit (sickness accident and disability). Do you have, or are you making an application for, any other income protection, mortgage payment protection insurance or accident and sickness cover policy? If Yes then for each of the covers you have in force, or applications you have made, please give the following details: For these types of cover, what is the total number of applications and policies that you have, or have made? What is the cover for? Income protection Mortgage payment protection Accident and sickness Income protection Mortgage payment protection Accident and sickness What is the amount of cover? Will the cover be cancelled when this plan starts? If No please answer the following 2 questions, otherwise please move on to the next section. At claim, what is the deferred period before payment is made? At claim, will the benefit be paid for the full term of the cover? If No, what is the payment period of the cover? weeks weeks months months If you need to tell us about more policies or applications please use the additional information page at the back of this form. If you are applying for Unemployment benefit please answer the following questions. Please read the definition of Employed and Self employed in the Self Assurance product guide before you answer the following questions to see if you are eligible for this benefit. Have you been employed continuously (or trading continuously under the same name if self employed) for the past 6 consecutive months? First life Second life Please note: if you answer No to this question we will not be able to offer you unemployment benefit. Are you currently in dispute or in the course of any disciplinary action with your employer or do you know of any circumstances which could result in or put you at risk of becoming unemployed? Circumstances could include, but are not restricted to, loss of a major contract; internal restructure; profits warning; strategic reviews of part of or all of the business; change of ownership or any cost cutting programme. Please note: if you answer Yes to this question we will not be able to offer you unemployment benefit. 5

6 Lifestyle First life Second life What is your height? What is your weight? If you are currently pregnant, please tell us your weight immediately before your pregnancy Have you smoked or used any tobacco, nicotine replacement products or E-cigarettes in the last 12 months? If Yes please go to the question Which of these tobacco, nicotine replacement products or E-cigarettes have you used in the last 12 months? If No please go to the question Which of the following are you? Which of the following are you? We may require a simple test to confirm this. If Ex-smoker, User of nicotine replacement products or User of E-cigarettes in the last 12 months, please go to the question How much of each of the following products did you use on a daily basis before stopping? If Occasional smoker, please go to the question Which of these tobacco, nicotine replacement products or E-cigarettes have you used in the last 12 months? If you are an ex-smoker, user of nicotine replacement products or user of E-cigarettes in the last 12 months, how much of each of the following products did you use on a daily basis before stopping? ft in or m cm ft in or m cm st lbs or kg st lbs or kg Life-long non-smoker Ex-smoker Occasional smoker User of nicotine replacement products in the last 12 months Cigarettes Cigars Pipes User of E-cigarettes in the last 12 months Nicotine replacement products E-cigarettes Life-long non-smoker Ex-smoker Occasional smoker User of nicotine replacement products in the last 12 months Cigarettes Cigars Pipes User of E-cigarettes in the last 12 months Nicotine replacement products E-cigarettes Other If Other, please provide details: Other If Other, please provide details: When did you last use any tobacco, nicotine replacement products or E-cigarettes? Which of these tobacco, nicotine replacement products or E-cigarettes have you used in the last 12 months? M M Y Y Y Y M M Y Y Y Y Cigarettes Cigarettes Cigars Cigars Pipe tobacco Nicotine replacement products E-cigarettes Other If Other, please provide details: Pipe tobacco Nicotine replacement products E-cigarettes Other If Other, please provide details: 6

7 Lifestyle (Continued) First life Second life How much of the following products do you use on a daily basis? Cigarettes Cigars Cigarettes Cigars Pipes Nicotine replacement products E-cigarettes Other If Other, please provide details: Pipes Nicotine replacement products E-cigarettes Other If Other, please provide details: How many units of alcohol do you drink in a typical week? 1 pint of beer = 2 units 1 glass of wine (175 ml) = 2 units 1 measure of spirits = 1 unit Have you ever been medically advised to reduce your alcohol consumption or been disqualified from driving in the last 5 years? This includes being referred for treatment or specialist support such as an alcohol addiction unit or Alcoholics Anonymous. We do not need to know about any spent driving convictions. If Yes, please provide details on the additional information page at the back of this form. Have you used recreational drugs during the last 10 years? Examples of recreational drugs include ecstasy, cannabis, cocaine, heroin, amphetamines and anabolic steroids. If Yes please provide details on the additional information page at the back of this form. Do you intend to take part in any of the following activities? Flying includes hang gliding, microlighting, parachuting and skydiving. Please ignore one off parachute jumps. Do not select Flying if you only fly as a fare paying passenger or cabin crew on a scheduled or charter aircraft. Extreme sports include, for example, bungee jumping, canyoning, white water rafting. Please tick all that apply. units units Flying Flying Motor car or motorcycle sport Motor car or motorcycle sport Mountaineering or rock climbing Mountaineering or rock climbing Powerboat racing Powerboat racing Caving or potholing Caving or potholing Diving Diving Sailing (other than inland) Sailing (other than inland) Horse riding (other than private hacking) Professional sport Martial arts Off-piste snow sport Any extreme sport No to all Horse riding (other than private hacking) Professional sport Martial arts Off-piste snow sport Any extreme sport No to all If you intend to take part in any of the above activities please give full details of all the activities you take part in i.e. how often you do this and where. 7

8 Occupation and travel First life Second life What is your occupation? How much did you earn over the last 12 months before tax? This should be your gross (pre tax) earnings from your employment or self employment. Which industry do you work in? Does your occupation involve manual work, driving or working at heights? If Yes, please advise what percentage of your working day. % Manual work % Manual work % Driving % Driving % Working at heights % Working at heights Typical height (ft) Typical height (ft) % Percentage of time spent at the typical height % Percentage of time spent at the typical height Are you involved in any of the following hazardous duties? Armed forces Territorial Army or Reservist duties Oil or gas platform work Working on a fishing vessel at sea Merchant marine Commercial diving Tunnelling or underground work Working with explosives Working with asbestos None of the above Armed forces Territorial Army or Reservist duties Oil or gas platform work Working on a fishing vessel at sea Merchant marine Commercial diving Tunnelling or underground work Working with explosives Working with asbestos None of the above Have you lived, worked or travelled outside the UK, European Union, North America, Japan, Australia or New Zealand during the last 2 years or do you intend to do so in the next 2 years? Ignore holidays of up to a month. If Yes please give us the name of each country together with the reason, frequency and duration of each visit. Please also include the area within each of the countries you list. 8

9 General medical history First life Second life Have you ever had, or do you currently have, any of the following? Any form of cancer, tumour, lymphoma, leukaemia or any brain or spinal growth or cyst? Including: Hodgkin lymphoma Non-Hodgkin lymphoma Leukaemia Melanoma Heart disease or disorder, circulatory disease or diabetes? Including: Angina or heart attack Disease of, or surgery to, your heart or arteries Cardiomyopathy Heart valve or heart structure abnormalities Irregular or rapid heart beat Aortic aneurysm Peripheral vascular disease Heart murmur Deep Vein Thrombosis (DVT) A stroke, brain haemorrhage or surgery to your blood vessels in the brain or neck? Including: Stroke or mini-stroke Transient ischaemic attack Brain or artery surgery Brain injury Aneurysm Any bleeding within the skull Multiple Sclerosis or been diagnosed with any neurological disorder? Including: Parkinson s disease Epilepsy, fit or seizure Optic or retrobulbar neuritis Alzheimer s disease Dementia Cerebral palsy Paralysis Muscular dystrophy Motor neurone disease 9

10 General medical history (Continued) First life Second life Any mental health issue that has required hospital treatment or referral to a specialist, or have you considered or attempted self-harm? Including: Specialist clinic or referral to a psychiatrist Attempting suicide A positive test for HIV/AIDS or Hepatitis B or C, or are you awaiting the results of such a test? If the results of a test you are waiting for turns out to be negative, the fact that you had a test won t affect the acceptance terms we offer you. Your family First life Second life Have any of your parents, brothers or sisters ever been diagnosed with or died from any of the following conditions before the age of 60? Screening includes any test, investigation or blood test. In line with the ABI s policy on genetics and insurance, you do not need to tell us about any predictive genetic test result you have had unless you are applying for life insurance which, when added to any existing life insurance policies you have, exceeds 500,000 of death cover, 300,000 of critical illness or death or earlier critical illness or 30,000 each year for Disability income benefit. If you are applying for life insurance which exceeds 500,000 of death cover, 300,000 of critical illness or death or earlier critical illness cover or 30,000 each year for Disability income benefit, when combined with any of your existing life insurance policies, you need to tell us in this application form about any predictive genetic test results you have had for Huntington s disease. If you have had any genetic test and feel that the result may be in your favour then you may inform us of this if you wish. Heart attack or Angina Stroke Diabetes Cancer Leukaemia or lymphoma Multiple Sclerosis Huntington s disease Cardiomyopathy Polycystic kidney disease Muscular dystrophy Motor neurone disease Alzheimer s disease Parkinson s disease Haemochromatosis Familial colon polyps Heart attack or Angina Stroke Diabetes Cancer Leukaemia or lymphoma Multiple Sclerosis Huntington s disease Cardiomyopathy Polycystic kidney disease Muscular dystrophy Motor neurone disease Alzheimer s disease Parkinson s disease Haemochromatosis Familial colon polyps Any other disorder which runs in your family for which you have received or been advised to have screening for None of the above Any other disorder which runs in your family for which you have received or been advised to have screening for None of the above For each condition please answer the following questions: What is the name of the first condition that any of your parents, brothers or sisters has had before the age of 60? Where this is cancer, please be specific as to the type of cancer. How many of your parents, brothers or sisters have had this condition? 10

11 Your family (Continued) First life Second life For each relative with this condition, please tell us their relationship to you and the age that they were diagnosed with this condition. What is the name of the second condition that any of your parents, brothers or sisters has had before the age of 60? Where this is cancer, please be specific as to the type of cancer. How many of your parents, brothers or sisters have had this condition? For each relative with this condition, please tell us their relationship to you and the age that they were diagnosed with this condition. If you need to tell us about any more conditions please use the additional information page at the back of this form. Recent medical history in the last 5 years First life Second life Apart from anything you have already told us about, during the last 5 years have you had, or do you currently have, any of the following: Raised blood pressure, raised cholesterol or chest pain? Anxiety, depression, stress or mental illness? Including: Work stress Insomnia Eating disorders Persistent tiredness or fatigue Addiction Any treatment or medication for mental illness e.g. counselling, tablets (whether taken or not). Numbness, pins and needles, tremor, change in skin sensation, tingling, muscle weakness, loss or reduced power in limbs, difficulty with co-ordination or persistent tiredness or fatigue? This includes symptoms that you have had even if you have not consulted a doctor. 11

12 Recent medical history in the last 5 years (Continued) First life Second life Any form of joint pain, arthritis or neck, back, spine, or muscle pain or stiffness? Including: Back or neck pain, stiffness or surgery Joint pain, stiffness or surgery (including that affecting your knees, shoulders, hips, ankles, wrists or hands) All forms of arthritis Repetitive strain injury (RSI) Gout Muscle strain Any condition affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses? Including: Blindness or impaired vision Deafness or impaired hearing Blurred or double vision Tinnitus, Menieres disease, Labyrinthitis Glaucoma A tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed in appearance or become painful? Please answer Yes whether seen by a doctor or not. Asthma, bronchitis, or any other disorder affecting your lungs or breathing? Including: Sleep apnoea Sarcoidosis Emphysema Pneumonia You do not need to tell us about: Common colds or flu One-off chest infections that you have fully recovered from Any stomach, digestive system, liver or blood disorder? Including: Liver, pancreas and gall bladder conditions Bowel disorder Crohn s disease Ulcerative colitis Anaemia Clotting disorders Hepatitis Gastric and duodenal ulcers Disorders of the oesophagus including Barrett s oesophagus 12

13 Recent medical history in the last 5 years (Continued) First life Second life Any disorder of the kidney, bladder, prostate or thyroid? Including: Blood or protein in the urine Multiple urine infections Kidney or bladder stones Over or under-active thyroid Recent medical history in the last 3 years Apart from anything you have already told us about, in the last 3 years have you: Been prescribed medication or treatment regularly for a period of 4 consecutive weeks or more, or have you been under review from your doctor or a medical professional? Including: Physio Counselling Prescriptions from your own doctor even if you did not take them You do not need to tell us about contraception, fertility, dental treatment or reviews purely in relation to pregnancy. Been referred to a specialist or had or been advised to have any investigations? Including: Blood tests Biopsy Ultrasound, X-Ray, CT/MRI or other scan ECG, echocardiogram or other heart investigation Abnormal smear or abnormal mammogram Investigations using an internal camera such as an endoscopy, colonoscopy or laparoscopy You do not need to tell us about investigations which were purely for pregnancy, infertility or simple fractures which have been resolved with no time off work, or about genetic tests that meet the criteria outlined on page 2. 13

14 Recent medical history in the last 3 years (Continued) First life Second life In addition, apart from anything else you have already told us about: Are you awaiting referral, investigation, results or treatment for anything else or do you have any other symptoms for which you have not yet sought medical advice? For example: Bleeding from the bowels, change in bowel habit Persistent cough Weight loss Onset of fits and seizures Dizziness, blackouts/fainting A mole or blemish which has changed in appearance or any lump or growth If you are applying for Disability income benefit, Total and permanent disability or Premium payment benefit (sickness, accident and disability), please answer the following questions: Through illness or injury in the last 2 years, which of the following apply? Currently off work Altered duties in the last 2 years Currently off work Altered duties in the last 2 years Reduced hours in the last 2 years Required more than 4 consecutive weeks off work None of the above Reduced hours in the last 2 years Required more than 4 consecutive weeks off work None of the above Do you have another occupation in addition to the one stated above? If Yes please state that occupation For each of the general and recent medical history questions you have answered Yes to please provide the following information. This will help us to assess the application but please be aware that the questions might not exactly match the questions that are asked during an online application. Additional medical details 1 First life Second life What is the name of the medical condition? When did symptoms first occur? Do you have recurrent symptoms? If Yes, please state how many episodes or attacks of symptoms you have had since the onset of the condition. How often do you have symptoms? All the time Daily Weekly Monthly Infrequently No longer have symptoms All the time Daily Weekly Monthly Infrequently No longer have symptoms 14

15 Additional medical details 1 (Continued) First life Second life If you no longer have symptoms, when did you last have symptoms? Please describe the nature and severity of the symptoms. Do these symptoms restrict you in any way? Have you seen a specialist for the condition? If Yes, please give details of the specialist s name and hospital. What medical investigations have been performed? Are you awaiting any investigations, tests, or referral to a specialist? Have you had any surgery, investigations or tests for this condition? If Yes, please give full details. What treatment have you been prescribed? Is it continuing? How many days have you been off work because of this condition? Which of the following best describes the severity of your condition? Fully recovered with no remaining disability Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Daily activities or tasks significantly or regularly restricted Fully recovered with no remaining disability Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Daily activities or tasks significantly or regularly restricted 15

16 Additional medical details 2 First life Second life What is the name of the medical condition? When did symptoms first occur? Do you have recurrent symptoms? If Yes, please state how many episodes or attacks of symptoms you have had since the onset of the condition. How often do you have symptoms? All the time All the time If you no longer have symptoms, when did you last have symptoms? Please describe the nature and severity of the symptoms. Daily Weekly Monthly Infrequently No longer have symptoms Daily Weekly Monthly Infrequently No longer have symptoms Do these symptoms restrict you in any way? Have you seen a specialist for the condition? If Yes, please give details of the specialist s name and hospital. What medical investigations have been performed? Are you awaiting any investigations, tests, or referral to a specialist? Have you had any surgery, investigations or tests for this condition? If Yes, please give full details. What treatment have you been prescribed? Is it continuing? 16

17 Additional medical details 2 (Continued) First life Second life How many days have you been off work because of this condition? Which of the following best describes the severity of your condition? Fully recovered with no remaining disability Fully recovered with no remaining disability Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Daily activities or tasks significantly or regularly restricted Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Daily activities or tasks significantly or regularly restricted Additional medical details 3 First life Second life What is the name of the medical condition? When did symptoms first occur? Do you have recurrent symptoms? If Yes, please state how many episodes or attacks of symptoms you have had since the onset of the condition. How often do you have symptoms? If you no longer have symptoms, when did you last have symptoms? Please describe the nature and severity of the symptoms. All the time Daily Weekly Monthly Infrequently No longer have symptoms All the time Daily Weekly Monthly Infrequently No longer have symptoms Do these symptoms restrict you in any way? Have you seen a specialist for the condition? If Yes, please give details of the specialist s name and hospital. What medical investigations have been performed? 17

18 Additional medical details 3 (Continued) First life Second life Are you awaiting any investigations, tests, or referral to a specialist? Have you had any surgery, investigations or tests for this condition? If Yes, please give full details. What treatment have you been prescribed? Is it continuing? How many days have you been off work because of this condition? Which of the following best describes the severity of your condition? Fully recovered with no remaining disability Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Daily activities or tasks significantly or regularly restricted Fully recovered with no remaining disability Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Daily activities or tasks significantly or regularly restricted Additional medical details 4 First life Second life What is the name of the medical condition? When did symptoms first occur? Do you have recurrent symptoms? If Yes, please state how many episodes or attacks of symptoms you have had since the onset of the condition. How often do you have symptoms? All the time Daily Weekly Monthly Infrequently No longer have symptoms All the time Daily Weekly Monthly Infrequently No longer have symptoms 18

19 Additional medical details 4 (Continued) First life Second life If you no longer have symptoms, when did you last have symptoms? Please describe the nature and severity of the symptoms. Do these symptoms restrict you in any way? Have you seen a specialist for the condition? If Yes, please give details of the specialist s name and hospital. What medical investigations have been performed? Are you awaiting any investigations, tests, or referral to a specialist? Have you had any surgery, investigations or tests for this condition? If Yes, please give full details. What treatment have you been prescribed? Is it continuing? How many days have you been off work because of this condition? Which of the following best describes the severity of your condition? Fully recovered with no remaining disability Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Fully recovered with no remaining disability Ongoing condition with no restrictions in daily activities or mobility Mild symptoms with infrequent Moderate symptoms with infrequent Severe symptoms with infrequent Daily activities or tasks significantly or regularly restricted If you need to tell us about further conditions please use the additional information page. Daily activities or tasks significantly or regularly restricted 19

20 20 Additional information

21 Additional information 21

22 22 Additional information

23 GP details First life Second life Name of doctor or practice Address Postcode Telephone Adviser details for adviser use only I, or my company, have all the appropriate authorisations from the appropriate regulatory authority for this application. If the application arises as a result of the activities of another person, then that person is also appropriately authorised or is exempt from authorisation. Company name The adviser s contact name Address Postcode Telephone Fax Scottish Provident agency number Scottish Provident sales contact National network (if applicable) Portfolio Member Services The adviser s case reference Yes No 23

24 Payment details Is the person paying for this plan the applicant? The applicant will usually be the person/ people covered unless you have told us something different on page 3. What is the plan payer s full name and address? If a company is paying for this plan and your adviser hasn t verified the company s identity then we may need to ask for more detailed information when we receive your application. Yes No If the applicant is paying for this plan, please only answer the questions in the following sections Plan start date and Trusts. If the applicant is not paying for this plan, the payer must complete and sign the direct debit details and post it to us when you submit the application. Name Address Postcode Plan payer s date of birth (individuals only) D D M M Y Y Y Y What is the plan payer s relationship to the applicant? Wife Husband Partner/Co-habitant Business partner Company Employer Other How would you, or the person paying for this plan, like to pay? Depending on the start date of your plan, the first payment may not be collected on the day you choose. We will write to you at least 10 working days before we collect the first payment. Is more than one signature required to authorise payments If Other, please give details Monthly by direct debit Please tell us the day of the month you would like us to collect your payment Yearly by direct debit Yes No If Yes, both people must complete and sign the direct debit mandate on page 31. You must then post the signed direct debit mandate to us when you submit the application. D D Account details Account details for the direct debit payments Name of account holder Sort code Account number 24

25 Start date Please tell us when you would like the plan to start. For a joint life application we will not start your plan until we have accepted both lives Immediately when you accept my application To be advised On the date I tell you below D D M M Y Y Y Y Identity verification Have the required identity verification checks been completed? Yes No Scottish Provident has a statutory requirement to verify identity (in line with UK Money Laundering Legislation and FCA Regulations). We may therefore need confirmation of the applicant s identity and address. Please ensure you follow the instructions below where appropriate. Failure to provide the necessary requirements will result in a delay to processing of this application. FOR INTERMEDIARY USE If the premium for the plan is over 50 per month or 600 per year, and the source of funds concession is not applicable, you will need to complete an introduction verification certificate for each applicant/ third party payer. The form (individual or corporate) is available on our website at Please also note that further verification of identity may be required during the lifetime of the plan or at claim. Trusts Is this plan to be in trust? Yes No You can find details of our standard trusts at co.uk/scpr5376. If the plan is to be written under the business trust or relevant life policy trust the trust form must be completed before the plan starts. If these trust forms have not yet been completed please choose To be advised for when the plan is to start. Is this plan to be written as a relevant life policy? Yes To be a relevant life policy: the application must be for a Self Assurance Term Business plan, the appplicant must be the employer and the life assured an employee, the plan must only include death benefits, and the term of the plan must not go beyond the 75th birthday of the life assured. Declaration Please sign and return to: New Business, Scottish Provident, 301 St Vincent Street, Glasgow G2 5PB. Please note: We will accept a faxed copy of this permission to enable processing of your application to begin. If you would like to fax the permission to Scottish Provident, please fax it to Application for protection You have filled in a Self Assurance application form and this has been sent electronically to Scottish Provident. We have sent an acknowledgment of receipt of your application form to your financial adviser. The policy/reference number of your plan is If you wish to contact us please quote this reference. Changes of circumstances It is very important that you tell us if there has been a change to any of the answers to the questions within the application (including in relation to your health, occupation or leisure activities) or any other information you or the life assured provide between the date the answer or the information is provided and the date Scottish Provident starts your plan. If you do not do this, and this affects the terms we would have offered you, your insurance may be cancelled and may not pay out in the event of a claim. Important information We may need to share the application information with our agent for the purposes of requesting medical information or arranging examinations. If you are applying for insurance with other companies at the same time as this, by signing the declaration you are agreeing to copies of any medical reports prepared on your behalf being shared between Scottish Provident and these other companies. If, however, another company asks us to provide copies of highly sensitive information (for example HIV test results), we will ask for your written permission before we do so. We may ask you to contact your doctor if we are waiting for reports we have asked for. You can ask us for copies of the product guide, the completed application form and the ABI Genetic Testing Code of Practice. 25

26 Data protection and identity verification statement How we use your personal information We, the Royal London Group (including Scottish Provident), may obtain personal information either from you directly, or with your consent, from your approved financial adviser or from other sources such as your doctor or an identity authentication agency. We will 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 will retain your personal information for a reasonable period and we may also share information about you (in the UK and abroad) with other companies within the Royal London Group, your approved financial adviser, 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 financial adviser 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 the box if you do not wish to receive these communications. Applicant 1 Life 1 Life 2 We may carry out an electronic check to verify your identity. We will use a reputable reference agency who will access a range of data sources including information from the Electoral Register to carry out identity checks. Although we will retain a record of this search, we will not share this information outside of the Royal London Group. We will 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 will 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 have appointed you to act for them to consent to the processing of their personal data and that you have 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 us not to process your personal data for marketing purposes. We will usually inform you at the point of collection if we intend to use your data for such purposes or if we intend to disclose your information to any third party for such purposes. You can exercise your right to prevent such processing by checking the appropriate boxes on the application form. You can also exercise the right at any time by writing to us. You have the right to ask for a copy of the information that we hold on you, for which we are entitled to charge a small fee and to have any inaccuracies in your information corrected. Please write to: New Business, Scottish Provident, 301 St Vincent Street, Glasgow G2 5PB. 26

27 Access to Medical Reports Please sign and return to: New Business, Scottish Provident, 301 St Vincent Street, Glasgow G2 5PB. Please note: We will accept a faxed copy of this permission to enable processing of your application to begin. If you would like to fax the permission to Scottish Provident, please fax it to Application for protection You have filled in a Self Assurance application form and this has been sent electronically to Scottish Provident. We have sent an acknowledgement of receipt of your application form to your financial adviser. The policy/reference number of your plan is If you wish to contact us please quote this reference. Changes of circumstances It is very important that you tell us if there is a change to any of the answers to the questions within the application (including in relation to your health, occupation or leisure activities) or any other information you or the life assured provide between the date the answer or information is provided and the date Scottish Provident starts the plan. If you do not do this, and this affects the terms we would have offered you, your insurance may be cancelled and may not pay out in the event of a claim. Important information We may need to share the application information with our agent for the purposes of requesting medical information or arranging examinations. If you are applying for insurance with other companies at the same time as this, by signing the declaration you are agreeing to copies of any medical reports prepared on your behalf being shared between Scottish Provident and these other companies. If, however, another company asks us to provide copies of highly sensitive information (for example HIV test results), we will ask for your written permission before we do so. We may ask you to contact your doctor if we are waiting for reports we have asked for. You can ask us for copies of the product guide, the completed application form and the ABI Genetic Testing Code of Practice. 27

28 Access to medical reports We may need to get medical reports to support your application. Before we can ask any doctor that you have consulted to fill in a report, we need your permission under the Access to Medical Reports Act 1988 and the Access to Personal Files and Medical Reports (Northern Ireland) Order Your rights are as follows: You do not need to give your permission, but if you do not, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance. You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to keep the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us. If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being 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 think that any part of the report is not correct or is misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him or her to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others. 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 in the last three years your past health details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultations 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 have 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 have 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: New Business, Scottish Provident, 301 St Vincent Street, Glasgow G2 5PB. 28

29 Declaration Scottish Provident is a division of the Royal London Group which consists of The Royal London Mutual Insurance Society Ltd and its subsidiaries. Please sign this declaration once you have read and agree to it, together with the important information, data protection and identity verification statement and notes on the Access to Medical Reports Act 1988 and the Access to Personal Files and Medical Reports (Northern Ireland) Order I have read the answers to all the questions in this application and I confirm that the statements made in, or in connection with, this application, whether in my handwriting or not, are true and complete as far as I know. I understand that if I leave out any relevant information in answering the questions, or give incomplete or incorrect information, it may lead to my plan being cancelled and may not pay out in the event of a claim. If my circumstances change in any way before the plan starts after completing this form, I will tell you. I understand that if I do not do this, my plan may be cancelled and may not pay out in the event of a claim. I agree to you or your agents asking any doctor I have consulted about my physical or mental health to provide medical information so First life you may assess my application. You may request relevant information from, or share relevant information with, other insurers in connection with this application or any other of my applications for life, critical illness, sickness, disability, accident or private medical insurance. I authorise those asked to provide the requested medical information when they see a copy of this consent form. I understand that you may request medical information within six months of the start of my plan in order to check the accuracy of any statement made in, or in connection with, this application. If you choose to do this, I agree to you or your agents asking any doctor I have consulted about my physical or mental health and for those asked to provide the requested information. I understand that if any statement is inaccurate, incomplete or incorrect, and this affects the terms that you would have offered, my plan may be cancelled and may not pay out in the event of a claim. I have read the declaration, important notes, data protection and identity verification statement and information relating to my rights under the Access to Medical Reports Act 1988 and Access to Personal Files and Medical Reports (Northern Ireland) Order Please tick the box if you want to see any report before it is sent to us. First Life Second Life Second life Signature of life assured Date D D M M Y Y Y Y D D M M Y Y Y Y Name Postcode Date of birth D D M M Y Y Y Y D D M M Y Y Y Y Once submitted electronically we will provide you with a policy number please enter that number here If you wish to contact us please quote this reference number. Scottish Provident is a division of the Royal London Group, which consists of The Royal London Mutual Insurance Society Limited and its subsidiaries. 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 and is a member of the Association of British Insurers and the Association of Financial Mutuals. Registered in England and Wales number Royal London Marketing Limited is authorised and regulated by the Financial Conduct Authority. The firm is on the Financial Services Register, registration number and introduces Royal London s customers to other insurance companies. Registered in England and Wales number Registered office for both companies: 55 Gracechurch Street, London, EC3V 0RL. SCPR6342 SEP14 LD 29