Data capture form. For financial advisers only. Whole of Life. Version number 06/15

Transcription

1 For financial advisers only Whole of Life Data capture form Version number 06/15 See the following page for important notes you should read before completing this form. For the purposes of Financial Conduct Authority reporting: Did you give the applicant(s) advice about choosing to set up this policy? Adviser reference Tell us your adviser reference as it applies within your own organisation. Page 1 of 50

2 About this form This form is split into two parts: Part A allows you to get an illustration from our online services Part B allows you to collect the further information we need to progress that online illustration to an online application You may have to contact your client(s) if we need additional underwriting information the information you enter online will automatically be saved for 30 days if you need to get in touch with your client(s). You can download additional point of sale questionnaires at aegon.co.uk. You can also get copies of all our trust literature from our website or by getting in touch with our Customer Service Centre. Protection Customer Service Centre protect_support@aegon.co.uk Telephone: Fax: Underwriting helpline: Online service exclusions Our online service doesn t process cases where: n the life/lives to be assured aren t prepared to submit bank information online n the Direct Debit payments aren t being made from the life/lives to be assured s personal UK bank account n the life/lives to be assured haven t been informed of how their personal data will be processed n the source of funds concession isn t being used for money laundering requirements n the life/lives to be assured has/have more than one occupation n there s no insurable interest n the life/lives to be assured are resident outside England, Scotland, Wales or rthern Ireland n the life/lives to be assured are resident in the Channel Islands or Isle of Man n the life/lives to be assured aren t the same as the applicant(s) Policy and any free cover in trust If this policy and any free cover is to be held in trust complete section 6. Before doing this, make sure you ve read our Whole of Life trust guide and given your client(s) a copy of the guide and the Trust terms and powers booklet, code number WLT available at aegon.co.uk About free cover When your client(s) apply and if eligible, we ll provide free cover for up to 90 days while their application s being processed and before full cover can be put in place. For full details of free cover, please read our Key features and the Addendum to our Policy conditions. Checklist: I ve given a copy of the Key features document to the client(s) I ve given the pull out page Your online application what happens next? (page 41) to the client(s) If to be held in trust, I ve given a copy of the Whole of Life trust guide and the Trust terms and powers booklet, code number WLT to the client(s), and two copies of the Form of Authority have been signed by the client(s) I ve reminded the client(s) of the importance of answering the questions fully and accurately Additional information Make sure you send us the following additional information, where necessary: Completed point of sale questionnaires if not already entered into our online new business service Additional personal information if your client(s) has chosen to write to our Chief Medical Officer separately Any documentation you send us needs to include the online application reference number, which you can find at the top right-hand side of the online services new business screens. Whenever you see this icon, you may need to send us additional material. Any additional information, including the General practitioner s report consent declaration, should be sent to us at Aegon, Edinburgh Park, Edinburgh EH12 9SE Whole of Life Data capture form Page 2 of 50

3 Part A The following information is needed for you to get an illustration from our online services First life to be assured () Full forename(s) Second life to be assured () Full forename(s) Surname Surname Date of birth (dd/mm/yyyy) Date of birth (dd/mm/yyyy) Gender Gender Male Female Male Female Tobacco and nicotine usage If you tell us that you ve smoked tobacco or used any other tobacco or nicotine products in the last 12 months, you ll need to answer more questions about this on page 9. Do you currently smoke or have you, in the last 12 months, smoked or used any nicotine products, such as gum or patches? Tobacco and nicotine usage If you tell us that you ve smoked tobacco or used any other tobacco or nicotine products in the last 12 months, you ll need to answer more questions about this on page 9. Do you currently smoke or have you, in the last 12 months, smoked or used any nicotine products, such as gum or patches? If, we may ask for a simple medical test to confirm this. Employment basis only tick one box Employed full-time Employed part-time over 16 hours Employed part-time under 16 hours Self-employed Unemployed Occupation If, we may ask for a simple medical test to confirm this. Employment basis only tick one box Employed full-time Employed part-time over 16 hours Employed part-time under 16 hours Self-employed Unemployed Occupation Industry Industry Whole of Life Data capture form Page 3 of 50

4 Part A continued Your insurance On what basis would you like to set up your policy? Only tick one option Single-life Joint-life first death Joint-life second death How much do you want the sum insured to be? Would you like to include inflation-linking? Your payment details Payment frequency: Monthly by Direct Debit Yearly by Direct Debit Payment only complete this box if the policy is payment driven Protecting your payments Would you like to protect your payments? tell us below which definition of incapacity Only tick one box Own occupation Any suited occupation Activities of daily work Would you like to protect your payments? tell us below which definition of incapacity Only tick one box Own occupation Any suited occupation Activities of daily work The deferred period will start from the date of incapacity and will be 26 weeks. Whole of Life Data capture form Page 4 of 50

5 Commission details The commission details entered at illustration stage will be carried through to new business. Your Aegon agency number this is your UAN and comprises of 3 letters and 3 numbers. Is this application being provided for your own use, for example the intermediary or their appointed representative, employee, relative, or a relative of an employee of the intermediary? Only tick one box: Initial plus renewal (Indemnity) Lump sum paid then renewal commission paid after the indemnity period. Initial plus renewal (n-indemnity) Paid in regular instalments over the initial period then renewal commission paid after the initial period. Level Paid in regular instalments throughout the life of the policy. Would you like to give up any commission? what percentage do you want to give up? % Whole of Life Data capture form Page 5 of 50

6 Part B The following information is needed for you to progress your illustration to new business Only answer this question if joint cover is being applied for. Is there an insurable interest between the and? For example spouse/ civil partner, shared dependent children, joint domestic mortgage, living with partner, joint loan. Have you given your client(s) the Your online application what happens next? section at the back of this form? Source of funds concession Money laundering guidance includes a source of funds concession for reduced risk business such as Aegon protection business. Where the life/lives assured and the person making the policy payments are the same, the source of funds concession allows us to rely on a cheque or Direct Debit instruction from a UK bank account, in the life/lives assured individual or joint names, to provide evidence of identity. Is the source of funds concession being applied for this application? 1. Personal details additional Title Mr / Mrs / Miss / Ms / Other please specify Title Mr / Mrs / Miss / Ms / Other please specify Previous surname (if changed in the last five years) Previous surname (if changed in the last five years) Address Address Same as Postcode Postcode Whole of Life Data capture form Page 6 of 50

7 1. Personal details continued continued Daytime phone number continued Daytime phone number Mobile phone number Mobile phone number We might use your address and phone numbers to get in touch with you about your application and the policy. If you don t want us to send you information about our products, please tick the appropriate box under Client consent in section 5. Marital status only tick one box Single Married Civil partner Divorced Separated Widowed Engaged Total yearly earnings To be completed in all cases. If you re selfemployed, please give your net taxable earnings after allowable expenses. We might use your address and phone numbers to get in touch with you about your application and the policy. If you don t want us to send you information about our products, please tick the appropriate box under Client consent in section 5. Marital status only tick one box Single Married Civil partner Divorced Separated Widowed Engaged What s the relationship with the first life to be assured? For example spouse/civil partner, shared dependent children, joint domestic mortgage, living with partner, joint loan. Total yearly earnings To be completed in all cases. If you re selfemployed, please give your net taxable earnings after allowable expenses. Whole of Life Data capture form Page 7 of 50

8 2. Medical details You should answer the following questions. You must not assume that we ll write to your doctor. If you don t answer the questions fully and accurately, we may not pay a claim, and the whole policy may be cancelled, not just the benefit under which you re claiming. How tall are you? m cms ft inches How much do you currently weigh? kgs st lbs How tall are you? m cms ft inches How much do you currently weigh? kgs st lbs Have you been registered with a doctor in the UK for the past 12 months? Have you been registered with a doctor in the UK for the past 12 months? Name of current doctor Name of current doctor Surgery name Surgery name Address Address Phone number Postcode Phone number Postcode Have you been registered with your current doctor for more than 12 months? If, tell us your previous doctor s details below and on the next page Name of previous doctor Have you been registered with your current doctor for more than 12 months? If, tell us your previous doctor s details below and on the next page Name of previous doctor Whole of Life Data capture form Page 8 of 50

9 2. Medical details continued continued Surgery name continued Surgery name Address Address Phone number Postcode Phone number Postcode Tobacco and/or nicotine use If you ve told us in part A of this form that you ve smoked or used any type of tobacco or nicotine product in the last 12 months including, but not limited to, cigarettes, cigars, nicotine gum/patches, e-cigarettes or pipe/rolled tobacco, please answer the following questions. What nicotine product(s) have you used in the last 12 months? If you ve told us you smoke(d) cigarettes, cigars, pipe or rolled tobacco, what s the average amount you smoke(d) a day? If you ve told us that you haven t smoked or used any type of tobacco or nicotine product in the last 12 months, we may ask for a simple medical test to confirm this. Amount For pipe and rolled tobacco, tell us the average amount in grams. 1 ounce = 28 grams Amount For pipe and rolled tobacco, tell us the average amount in grams. 1 ounce = 28 grams Whole of Life Data capture form Page 9 of 50

10 2. Medical details continued Alcohol consumption Please answer both the questions below about alcohol consumption even if you don t drink/ have never drunk alcohol. How many units of alcohol do you drink on average each week? One pint of beer = 2.5 units, one 330ml bottle of beer = 1.5 units, one 175ml glass of wine = 2 units, one measure of spirits = 1 unit. If you don t drink alcohol please enter 0. units units Have you ever been advised to drink less/no alcohol? If, give full details of when and why this occurred, how many units you were drinking at the time, the results of any investigations and any treatment you received Whole of Life Data capture form Page 10 of 50

11 3. Personal questions You should answer the following questions. Travel In the next 12 months do you intend to live, work or travel abroad, or have you done so in the past five years? You don t have to tell us about holidays if they total less than 30 days in any 12-month period. If, complete the table below If, complete the table on the next page Future travel/ residence (next 12 months) Country/Countries Reason for visit (choose from lived abroad, moving abroad, business/work, holiday/leisure) Length of visit (in days) Past travel/residence (last five years) Future travel/ residence (next 12 months) Country/Countries Reason for visit (choose from lived abroad, moving abroad, business/work, holiday/leisure) Length of visit (in days) Past travel/residence (last five years) Whole of Life Data capture form Page 11 of 50

12 3. Personal questions continued Leisure Do you intend to take part in any hazardous activity? You don t need to include one-off events such as a parachute jump for charity. If, tick all that apply. Your adviser can give you additional questionnaires for each of these pursuits. Completing these will help speed up the underwriting process. If you don t have access to these questionnaires, please give full details of your activities in the Details section below. Aviation (other than as a fare-paying passenger on a licensed airline) Caving/potholing Motor sports Mountaineering (other than hill walking, trekking, abseiling, artificial wall climbing) Sailing Sports diving Other give details Aviation (other than as a fare-paying passenger on a licensed airline) Caving/potholing Motor sports Mountaineering (other than hill walking, trekking, abseiling, artificial wall climbing) Sailing Sports diving Other give details Details Give full details, including the activity you take part in, how often you take part in this activity, details of any related qualifications and any equipment you use. Other protection policies Does the total amount of protection under all your existing policies, together with this application and any pending or concurrent applications, exceed 800,000 for life cover or 500,000 for critical illness cover or total permanent disability (TPD)? give details of protection already in force, including any existing cover with us Policy benefit(s)* Amount Reason for Name of insurer protection *For example, life cover/death or earlier critical illness cover (no TPD)/death or earlier critical illness cover (with TPD)/critical illness cover (no TPD)/critical illness cover (with TPD)/TPD Whole of Life Data capture form Page 12 of 50

13 3. Personal questions continued continued Is any of your existing protection being cancelled? give details of which protection is to be cancelled, including the name of insurer and policy number Protection to be cancelled Name of insurer Policy number Give details of protection being applied for, including any other applications to us Policy benefit(s)* Amount Reason for protection Name of insurer *For example, life cover/death or earlier critical illness cover (no TPD)/death or earlier critical illness cover (with TPD)/critical illness cover (no TPD)/critical illness cover (with TPD)/TPD Is the intention that all of these applications will go in force if accepted? give full details Whole of Life Data capture form Page 13 of 50

14 3. Personal questions continued Other protection policies Does the total amount of protection under all your existing policies, together with this application and any pending or concurrent applications, exceed 800,000 for life cover or 500,000 for critical illness cover or total permanent disability (TPD)? give details of protection already in force, including any existing cover with us Policy benefit(s)* Amount Reason for protection Name of insurer *For example, life cover/death or earlier critical illness cover (no TPD)/death or earlier critical illness cover (with TPD)/critical illness cover (no TPD)/critical illness cover (with TPD)/TPD Is any of your existing protection being cancelled? give details of which protection is to be cancelled, including the name of insurer and policy number Protection to be cancelled Name of insurer Policy number Give details of protection being applied for, including any other applications to us Policy benefit(s)* Amount Reason for protection Name of insurer *For example, life cover/death or earlier critical illness cover (no TPD)/death or earlier critical illness cover (with TPD)/critical illness cover (no TPD)/critical illness cover (with TPD)/TPD Whole of Life Data capture form Page 14 of 50

15 3. Personal questions continued continued Is the intention that all of these applications will go in force if accepted? give full details You only need to answer the question about Reason for cover if the sum insured you re applying for is above 1,000,000. Reason for cover Tell us the reason(s) you re applying for this Whole of Life policy. (Select all that apply) Inheritance tax liability Family/Personal protection Other give full details Tell us the reason(s) you re applying for this Whole of Life policy. (Select all that apply) Inheritance tax liability Family/Personal protection Other give full details Whole of Life Data capture form Page 15 of 50

16 4. Health questions Please make sure that you answer all of the questions honestly and accurately. If you re in any doubt about the information we need, you should give full details. In line with the Association of British Insurers policy on genetics and insurance, you don t need to tell us about any genetic test result you ve had if this application, taken together with any other insurance policies you already have, totals 500,000 or less for life insurance, 30,000 or less for income protection insurance or 300,000 or less for other types of insurance. Above this limit, you might need to tell us about certain genetic test results when applying for insurance. We ll only be interested in genetic test results where the government s Genetics and Insurance Committee (GAIC) has approved them for insurers to use. If you think this may apply to you, please ask us for details of the current position. However, you must tell us if you either have a family history of, are experiencing symptoms of, or are having treatment for, a medical condition, including any genetically inherited condition. If you wish to tell us about a genetic test result which shows that you haven t inherited a genetic disorder, then we ll take this into account when setting your policy payments, provided your clinical geneticist confirms that the test result indicates a reduced risk of developing the inherited disease. You must not partially disclose information when answering any questions or assume that we ll write to your doctor. When answering the following health questions you don t need to tell us about common colds, influenza, hay fever, sinus trouble, wisdom teeth, vasectomy or shingles. HIV/AIDS Have you ever tested positive for HIV, hepatitis B or C, or are you waiting for the results of such a test? If the result is negative, the fact of having a HIV test won t, of itself, have any effect on your acceptance terms for insurance. If you d prefer to write to our Chief Medical Officer at our head office to answer this question, please tick the box opposite. If you answered, tick all that apply Whole of Life Data capture form Page 16 of 50 I ve tested positive for HIV I m waiting for a HIV test result I ve tested positive for hepatitis B or C I m waiting for a hepatitis B or C test result I ve tested positive for HIV I m waiting for a HIV test result I ve tested positive for hepatitis B or C I m waiting for a hepatitis B or C test result

17 4. Health questions continued HIV/AIDS continued Within the last five years have you tested positive, or been treated, for any disease which was transmitted sexually? If you d prefer to write to our Chief Medical Officer at our head office to answer this question, please tick the box opposite. If, give full details, including the duration of illness, investigations, date of diagnosis and treatment received. Within the last five years have you been exposed to the risk of HIV infection? HIV infection can be caught through unsafe sex, intravenous drug abuse, or blood transfusions or surgery undertaken outside the European Union. If you d prefer to write to our Chief Medical Officer at our head office to answer this question, please tick the box opposite. If, give full details, including dates If you want to write in confidence to our Chief Medical Officer, please send your details on a separate piece of paper direct to our Chief Medical Officer at Aegon, Edinburgh Park, Edinburgh EH12 9SE, giving your full name and date of birth. Please make sure you sign and date these details. Whole of Life Data capture form Page 17 of 50

18 4. Health questions continued Have you ever taken or injected any drugs that haven t been prescribed by a doctor? If, what s the name of the drug? Do you currently use this drug? If, when did you last use this drug (mm/yyyy)? How many times a month do you use/did you use this drug? If you want, you can complete and return a drugs questionnaire ask your financial adviser for a copy. Do you now have, or have you ever had, any of the following: Angina, heart attack, stroke, transient ischaemic attack (TIA), brain haemorrhage or brain injury? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? How many times have you suffered from this condition/how many attacks have you had? When did you last suffer from this condition/when was your last attack (mm/yyyy)? Have you made a full recovery? If, give full details Whole of Life Data capture form Page 18 of 50

19 4. Health questions continued Do you now have, or have you ever had, any of the following: Chest pain, palpitations, heart murmur or any disease or abnormality of your heart, pulse, veins or arteries? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? Have you had any medical investigations or hospital admissions in relation to this condition? Investigations include GP consultations, blood tests, ECG etc. Awaited Awaited If, give full details, including the results of any investigations and details of any underlying cause identified. How many times have you suffered from this condition? Have you had surgery in relation to this condition? If, when was the surgery (mm/yyyy)? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details When were your last symptoms (mm/yyyy)? Whole of Life Data capture form Page 19 of 50

20 4. Health questions continued Do you now have, or have you ever had, any of the following: Cancer, tumour, Hodgkin s disease, lymphoma or leukaemia? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? When did you last receive treatment for this condition (mm/yyyy)? Treatment includes surgery/ chemotherapy/radiotherapy/medication. How many times have you suffered from this condition? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details Diabetes or sugar in the urine? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? The following questions are for sugar in urine only: Do you still have sugar in your urine? What has a medical practitioner told you the underlying cause for the sugar in your urine is? The following questions are for gestational diabetes only: Are you currently pregnant? Has a medical practitioner confirmed that the diabetes has fully resolved following the birth? Whole of Life Data capture form Page 20 of 50

21 4. Health questions continued Diabetes or sugar in the urine? continued The following questions are for Type 1 or Type 2 diabetes only: Have you been diagnosed with any form of heart or vascular disease? What treatment are you currently receiving? Treatment includes insulin, tablets, diet etc. When did you last attend a diabetic clinic or see a medical practitioner about your diabetes (mm/yyyy)? Do you know the result of your latest blood pressure readings taken by a medical practitioner (systolic/diastolic)? If, what were the dates and readings (enter up to three readings)? Date (mm/yyyy) Systolic Diastolic Date (mm/yyyy) Systolic Diastolic Date (mm/yyyy) Systolic Diastolic If : When was your blood pressure last checked by a medical practitioner (mm/yyyy)? How did the medical practitioner describe the result of your last blood pressure check, for example normal or controlled, borderline, raised? Whole of Life Data capture form Page 21 of 50

22 4. Health questions continued Diabetes or sugar in the urine? continued Do you know the result of your latest cholesterol readings taken by a medical practitioner? If, what were the dates and readings (enter up to three readings)? Date (mm/yyyy) Reading Date (mm/yyyy) Reading Date (mm/yyyy) Reading If : When was your cholesterol last checked by a medical practitioner (mm/yyyy)? How did the medical practitioner describe the result of your last cholesterol test, for example normal or controlled, borderline, raised? Do you know the date and result of your latest HbA1c readings? If, what were the dates and readings (enter up to three readings)? Date (mm/yyyy) Reading Date (mm/yyyy) Reading Date (mm/yyyy) Reading Whole of Life Data capture form Page 22 of 50

23 4. Health questions continued Diabetes or sugar in the urine? continued Have you ever had any complications in relation to your diabetes, for example eye disorders, kidney problems, protein in your urine or neurological problems? If, give full details including date(s) and duration of any time off work. Have you ever had any episodes of hypoglycaemia requiring intravenous (IV) glucose, hospital admission or time off work? If, give full details, including date(s) of episode(s), treatment needed and duration of any hospital admissions or time off work. Whole of Life Data capture form Page 23 of 50

24 4. Health questions continued Do you now have, or have you ever had, any of the following: Any condition of the nervous system such as epilepsy, fits or blackouts, multiple sclerosis, Parkinson s disease, Alzheimer s disease, dementia, cerebral palsy or paralysis? If, give the precise medical diagnosis? When were you diagnosed with this condition (mm/yyyy)? The following questions are for epilepsy, fits or blackouts only: On average, how many attacks do you have in a year? When was your last attack (mm/yyyy)? Mental illness that has required referral to a hospital, community mental health team or psychiatrist? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? How many times have you suffered from this condition? When did you last suffer from this condition (mm/yyyy)? When did you last have any treatment for this condition (mm/yyyy)? Treatment includes medication, counselling etc. How many days have you taken off work in the last five years as a result of this condition? Have you ever attempted suicide? If, how many times and when was the last time? Whole of Life Data capture form Page 24 of 50

25 4. Health questions continued Do you now have, or have you ever had, any of the following: Any disorder of the eyes (including blurred or double vision) or the ears (including impaired hearing)? You can ignore sight problems corrected by glasses or contact lenses, or hearing problems corrected by hearing aids. If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? What caused this condition, for example congenital/from birth, accident/injury, disease/illness? Have you had surgery in relation to this condition? Do you have any residual vision/hearing impairment as a result of this condition? Which eye or ear is/was affected? How many times have you suffered from this condition? When were your last symptoms (mm/yyyy)? Raised blood pressure? If, when were you first noted to have raised blood pressure (mm/yyyy)? How many different types of medication do you take for your raised blood pressure? If you don t take any medication, has any medication ever been prescribed for your raised blood pressure? Whole of Life Data capture form Page 25 of 50

26 4. Health questions continued Raised blood pressure? continued Have you ever stopped or not taken your medication without the approval of a medical practitioner? Has your medication changed, the dosage increased or have you been referred for further investigation, other than regular follow-up checks, in the last six months? When was your blood pressure last checked by a medical practitioner (mm/yyyy)? Has a medical practitioner recommended that your blood pressure is checked on a regular basis? Do you know what your blood pressure was when it was last checked by a medical practitioner? If, what was it? Systolic Diastolic If, how did the medical practitioner describe the result of your last blood pressure check, for example normal or controlled, borderline, raised? Whole of Life Data capture form Page 26 of 50

27 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: Raised cholesterol? If, when were you first noted to have raised cholesterol (mm/yyyy)? When was your cholesterol last checked by a medical practitioner (mm/yyyy)? Do you know what your cholesterol reading was when it was last checked by a medical practitioner? If, what was your cholesterol reading? How is your cholesterol being treated, for example no treatment prescribed by a medical practitioner, diet, medication? How did the medical practitioner describe the result of your last cholesterol test, for example normal or controlled, borderline, raised? Has a medical practitioner recommended that your cholesterol is tested on a regular basis? A lump, growth or cyst of any kind, or any mole or freckle that has bled, become painful, changed colour or increased in size? If, give the precise medical diagnosis Where s the exact site of the cyst, lump, lesion or growth? When were you diagnosed with this condition (mm/yyyy)? Has the cyst, lump, lesion or growth been completely removed? Has the cyst, lump, lesion or growth been confirmed as benign (non-cancerous)? Whole of Life Data capture form Page 27 of 50

28 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: A lump, growth or cyst of any kind, or any mole or freckle that has bled, become painful, changed colour or increased in size? continued Are you currently receiving follow-up checks? If, give the date of the next follow-up (mm/yyyy) Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details Numbness, tingling, tremor, temporary loss of muscle power, or loss of balance or co-ordination? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? Please tell us of any underlying cause, if applicable. How many times have you suffered from this condition? Have you fully recovered with no ongoing symptoms, treatment or follow-up required? If, give full details Whole of Life Data capture form Page 28 of 50

29 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: Asthma, bronchitis or any other chest or lung disorder? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? How many times have you suffered from this condition? When did you last experience symptoms or take treatment for this condition (mm/yyyy)? Have you been admitted to hospital in the last two years? How many courses of steroid tablets, for example Prednisolone, have you taken in the last two years? How many days have you taken off work in the last 12 months as a result of this condition? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details Anxiety, depression, stress, fatigue or any form of nervous or mental disorder, including work-related stress? If, give the precise medical diagnosis When were you first diagnosed with this condition (mm/yyyy)? Are you currently suffering from this condition? Are you currently receiving medication and/or treatment or counselling? Have you ever received inpatient treatment due to this condition? Whole of Life Data capture form Page 29 of 50

30 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: Anxiety, depression, stress, fatigue or any form of nervous or mental disorder, including work-related stress? continued Have you ever received care by a psychiatrist or other medical professional other than your GP/practice nurse, or are you waiting to do so? How many times have you suffered from this condition? When did you last suffer from this condition or receive treatment/ counselling (mm/yyyy)? How many days have you taken off work in the last five years as a result of this condition? Have you ever attempted suicide? If, how many suicide attempts have you made and when was your last attempt (mm/yyyy)? Anaemia or any blood or thyroid disorder? If, give the precise medical diagnosis Please tell us of any underlying cause, if applicable. When were you diagnosed with this condition (mm/yyyy)? Do you take prescribed medication and/ or treatment for this condition? Have you been advised by a medical practitioner that your blood levels have returned to normal/that your condition is satisfactorily controlled? Whole of Life Data capture form Page 30 of 50

31 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: Any disorder of the digestive system, liver, stomach, pancreas or bowel, including gastric or duodenal ulcer, hepatitis, colitis or Crohn s disease? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? Have you had any medical investigations in relation to this condition? Awaited Awaited Please tell us of any underlying cause, if applicable. Have you had surgery in relation to this condition? Awaited Awaited How many times have you suffered from this condition? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details When were your last symptoms (mm/yyyy)? How many days have you taken off work in the last 12 months as a result of this condition? Whole of Life Data capture form Page 31 of 50

32 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: Any disorder of the kidney, bladder, prostate or genito-urinary system, including blood or protein in the urine? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? Have you had any medical investigations in relation to this condition? Awaited Awaited Please tell us of any underlying cause, if applicable. Have you had surgery in relation to this condition? Awaited Awaited How many times have you suffered from this condition? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details When were your last symptoms (mm/yyyy)? How many days have you taken off work in the last 12 months as a result of this condition? Whole of Life Data capture form Page 32 of 50

33 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: Any arthritis, gout, joint or muscle problems, including the knee(s), shoulder(s), neck, back or spine? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? Are you currently unable to work or carry out your usual daily activities? Please tell us of any underlying cause, if applicable. Have you had surgery in relation to this condition? Awaited Awaited If or Awaited, give full details of the surgery including joint(s) involved and date. How many times have you suffered from this condition? Which joint(s)/part(s) of the body does this condition affect? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details When were your last symptoms (mm/yyyy)? How many days have you taken off work in the last five years as a result of this condition? Whole of Life Data capture form Page 33 of 50

34 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: Any arthritis, gout, joint or muscle problems, including the knee(s), shoulder(s), neck, back or spine? continued The following question is for gout only: On average how many attacks do you have each year? The following question is for arthritis only: Which of the following best describes your condition? Tick one option only Pain/stiffness, mainly early morning/late evening, no limitation of movement in affected joints, no deformity of joints, able to walk unaided Pain/stiffness isn t limited to early morning/late evening, some limitation of movement in affected joints, some assistive devices needed, for example a device to open a screw bottle top, able to walk unaided complete freedom from stiffness/ pain, serious restriction of movement in affected joints, marked deformity of joints, need help with day-to-day activities, regularly use walking aids Whole of Life Data capture form Page 34 of 50

35 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: This question is for both males and females Any breast disorders, for example lumps, cysts, nipple discharge or inverted nipple, or an abnormal mammogram? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? Has this been fully investigated? If, give full details Have you been diagnosed with a cyst/ lump? For cyst/lump has the cyst, lump, lesion or growth been completely removed? For cyst/lump has the cyst, lump, lesion or growth been confirmed as benign (non-cancerous)? Are you currently receiving follow-up checks? If, what s the date of the next follow-up (mm/yyyy)? Whole of Life Data capture form Page 35 of 50

36 4. Health questions continued Other than previously stated, in the last five years have you had, been treated for or been advised to have follow-up for any of the following: This question is for females only An abnormal cervical smear or other gynaecological disorder from which you haven t fully recovered and/or been discharged from follow-up? If, give the precise medical diagnosis When did you first suffer from this condition (mm/yyyy)? When were your last symptoms (mm/yyyy)? What investigations have you had in relation to this condition? Investigations include GP consultations, blood tests, scans etc. What treatment have you had in relation to this condition? Treatment includes surgery, medication etc. Has the condition been confirmed as benign (non-cancerous)? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications and been discharged from follow-up? If, give full details The following questions are for borderline/abnormal smear tests only: What s the CIN (Cervical Intraepithelial Neoplasia) grading, if known? Have all of your subsequent smear tests been normal? Whole of Life Data capture form Page 36 of 50

37 4. Health questions continued To the best of your knowledge, have any of your parents, brothers or sisters, before the age of 65, died or suffered from any of the diseases/disorders indicated below? If, complete the table below If, complete the table on the next page Disease/Disorder Relationship Age at diagnosis Relationship Age at diagnosis Relationship Age at diagnosis Heart disease Stroke Diabetes Cancer or tumour give site/type Alzheimer s disease Parkinson s disease Polycystic kidney disease Polyposis of the colon Motor neurone disease Multiple sclerosis Huntington s disease Muscular dystrophy Hypertrophic cardiomyopathy (HOCM) Any other hereditary disorder give name of disorder Whole of Life Data capture form Page 37 of 50

38 4. Health questions continued Disease/Disorder Relationship Age at diagnosis Relationship Age at diagnosis Relationship Age at diagnosis Heart disease Stroke Diabetes Cancer or tumour give site/type Alzheimer s disease Parkinson s disease Polycystic kidney disease Polyposis of the colon Motor neurone disease Multiple sclerosis Huntington s disease Muscular dystrophy Hypertrophic cardiomyopathy (HOCM) Any other hereditary disorder give name of disorder Are you awaiting the results of any investigations or are you aware of any symptoms or complaints that you haven t consulted a doctor or received treatment for? If, give full details, including the symptoms or complaint you ve suffered. Whole of Life Data capture form Page 38 of 50

39 4. Health questions continued Do you have any other information to give us about any medical investigation, test or consultation, advice, counselling, operation, medication or treatment that you ve had or been advised to have or are currently having, but haven t already told us about? If, give the precise medical diagnosis When were you diagnosed with this condition (mm/yyyy)? Have you had any medical investigations or hospital admissions in relation to this condition? Investigations include GP consultations, blood tests, ECG etc. If, give full details, including the results of any investigations and details of any underlying cause identified. How many times have you suffered from this condition? Have you had surgery in relation to this condition? If, when was the surgery (mm/ yyyy)? Have you fully recovered with no ongoing symptoms, treatment, residual problems or complications? If, give full details When were your last symptoms (mm/yyyy)? Whole of Life Data capture form Page 39 of 50

40 5. Client consent Do you want to see any medical report before it s supplied to us? We might share your information with other members of the Aegon UK Group (which means Aegon UK and its subsidiary companies) and would like to keep you informed about our products and services that might interest you. We won t pass your information to other companies outside the Aegon UK Group for marketing purposes. Unless you ve ticked the appropriate box below to object, you re consenting to receive marketing messages from the Aegon UK group of companies by post. I don t want to be contacted by post with marketing communications: I would like to be sent marketing communications in the following ways (please tick the relevant boxes): SMS Phone SMS Phone 6. Policy and any free cover in trust A trust is a way of giving property to others without giving them full, immediate control over it. Make sure you ve read our Whole of Life trust guide and the Trust terms and powers booklet, and have copies of these. Our trust guide includes important details about the online process for setting up the trust, and an explanation of the nature and tax consequences of the trust. t using our online trust process Your adviser can choose not to set up a trust using our online process. They might do this if you d prefer to use a bespoke trust drafted by a solicitor, or if you simply don t want your policy to be in trust. 6.1 Is the policy, and any free cover available before we set up the policy, to be issued under trust from the start, using our online process? If a trust is to be created outside this process, or a trust isn t required, tick. make sure you follow the steps for setting up a trust as set out in our guide Whole of Life Data capture form Page 40 of 50

41 7. Policy start date On risk immediately on acceptance at standard terms To be advised if the case has been accepted, you can input a start date later through the Recall facility A future start date (dd/mm/yyyy) Acceptance terms are valid for a maximum of 30 days. Whole of Life Data capture form Page 41 of 50

42 The following information should be given to your client(s) Your online application what happens next? You ve chosen to apply online for a Whole of Life policy with Aegon. This document will tell you what happens next and contains some important notes for you. Policy and any free cover in trust A trust is a way of giving property to others without giving them full, immediate control over it. It s important to be aware that a trust creates legal entitlements and has financial and tax implications. Once created the trust can t simply be ignored. When a valid claim s made, and provided we have sufficient evidence of the trust s existence, the proceeds will be paid to your trustees rather than into your estate, and can be used to help meet an inheritance tax liability due on your estate. Before taking any steps to set up the Whole of Life trust, you should seek your own legal or other professional advice to make sure a trust is right for you, and that setting up the trust on the terms set out using our online process gives effect to your wishes and requirements. Setting up a trust using our online process You should read our Whole of Life trust guide. This explains more about the process for setting up the trust and the nature and tax consequences of the trust. You should speak to your financial adviser about the trust before you take any action and ask for a copy of the Trust terms and powers booklet, code number WLT. We can t accept responsibility for the tax or other consequences arising from using the Whole of Life trust integrated into our online application process. If you choose to set up a Whole of Life trust using our online services: n the policy, and any free cover available to you before your policy is issued, will be held in trust which means if we receive a valid claim, the proceeds will be paid to your trustees n you don t have to wait until the policy is set up before creating a trust for it n the trust will be irrevocable, meaning that it can t be undone, so it won t be possible to unwind it if you change your mind What happens next? n If you want to set up a Whole of Life trust using our online process, then before your adviser submits your application, you ll need to follow the steps set out in our Whole of Life trust guide. n Your adviser will complete and submit your application on your behalf using our online services. n As soon as we receive your electronic application, a Confirmation pack will be sent to the address of the first life to be assured. This will contain details for both lives to be assured if this is a joint application. The Confirmation pack will include: an Application record this will show the information that s been submitted electronically on your behalf a Declaration a Confirmation form a prepaid reply envelope Your Application record n Please read this document carefully to make sure all the information is correct. If there are any mistakes or missing information, you should complete section 1 of the Confirmation form and return it to us immediately. Whole of Life Data capture form Page 42 of 50

43 Your online application what happens next? continued Your Declaration n Please read this document carefully as it contains important information. Your Confirmation form n Please remember, both the and (where appropriate) should sign and date the Confirmation form and return it to us in the enclosed prepaid reply envelope. n By checking and returning the Confirmation form you can: make sure that you ve given us full and accurate information reduce the risk of the policy being lost or cancelled in the event of a claim, due to incomplete and/or inaccurate information confirm, if applicable, the trust that you orally declared to your adviser. This is important evidence of the trust for our records. n Please make sure your adviser has given you a copy of our Key features document, and if applicable the Trust terms and powers booklet for this product. Important notes It s important that you read the following information: n The questions we ve asked cover the facts that we think are important to our assessment of your application. The information input electronically by your adviser, together with any other information collected, will form part of the application that s submitted to us on your behalf. n Aegon is the data controller of the personal data that you, or someone on your behalf, gives us. We ll use the information you ve provided for purposes in connection with the contract (and related services) which you ve applied for. This includes the processes of underwriting, administration, claims management and customer complaint handling. n When answering a question, you re personally responsible for making sure you ve given complete and accurate information. You shouldn t make any personal assessment about whether the information is relevant or not, or assume that we ll write to your doctor for medical information. If you re in any doubt about the information required, you should give full details. n You must tell us in writing if there s any change in your circumstances, for example financial interest, health, lifestyle, occupation or employment status and/or recreational activities, between the date you answered the application questions and the start date of your policy. If there s any change in your circumstances at all, you should tell us. n If you don t give full and accurate information, as detailed above, all the protection provided by the policy could be lost or cancelled in the event of a claim, not just the benefit affected or the benefit that s being claimed under. n Please be aware that if you re applying for insurance with other companies at the same time, you consent to us sending copies of medical reports to these other companies if they ask for them. However, if they ask us for any highly sensitive information, including HIV or genetic test results, we ll ask your specific permission before we send it. Whole of Life Data capture form Page 43 of 50