PERSONAL MENU PLAN Data capture form for telephone application Information for advisers how to use our telephone application service To apply for a Royal London Personal Menu Plan, simply go to adviser.royallondon.com and log in to quote and apply. You ll be given the option to apply by telephone application where you can enter the information you ve captured from this form. Or, if your client is present, you can just enter the information we need directly. We will then call your client and ask them questions about their lifestyle and health that are relevant to their application. If two people are applying then we will have to speak to both of them but we can do this with separate calls. We will make appointments to speak to your client over the next 14 days, excluding Sundays and most public holidays. The times we use to make appointments are as follows: Monday Thursday between 8.30am and 8.45pm, Friday between 8.30am and 6.45pm and Saturday between 8.30am and 3.45pm. After the telephone call(s), we ll send your client a copy of the answers they ve given us. We ll ask them to confirm that the information provided is accurate and complete by signing and returning a confirmation form within 60 days. Important information for the person completing this form It s very important that you tell us if there s a change to any of the answers to the questions within the application (including in relation to the person covered s health, occupation or leisure activities) or any other information you or the person covered provide between the date the answer or information is provided and the date we start the plan. If you don t do this, and this affects the terms that we would offer you, your plan may be cancelled and may not pay out in the event of a claim. You can ask us for copies of the plan details, key facts, the completed application form and the ABI genetic testing code of practice. If you ve had a predictive genetic test for Huntington s disease, you only have to tell us the results if this application, when added together with any cover you have of the same type, is for more than: 500,000 of Life Cover 300,000 of Critical Illness Cover or Life or Critical Illness Cover, or 30,000 each year of Income Protection. However, if you ve had any genetic test and the results are in your favour, you can choose whether to tell us the results or not. You must tell us however, if you think you re having treatment for, or are experiencing symptoms of, a genetic condition. For financial advisers Quote number Protection Personal Menu Adviser name Account number Special commission instructions Your unique reference Page 1 of 13
1 Who will be the plan owner? Please remind your clients how important it is to answer all the questions on this form honestly and in full. Will the person or people covered also be the plan owner(s)? Yes No If Yes, please go to section 2. Title Mr Mrs Miss Ms Other (please give details) First name(s) Surname Date of birth D D M M Y Y Y Y What is the plan owner s relationship to the person or people covered? Wife Husband Civil partner Partner/co-habitant Common law spouse Business partner Company Employer Other If Other, please give details In which country is the plan owner permanently resident? UK Guernsey Other Jersey Isle of Man If Other, please give details In the next six months, will you be moving from the country in which you re permanently resident? If Yes, please give full details. What is the plan owner s address? Yes No Postcode Email Phone number Page 2 of 13
2 About the people covered Please remind your clients how important it is to answer all the questions on this form honestly and in full. Person 1 Person 2 Title Mr Mrs Miss Ms Mr Mrs Miss Ms Other (please give details) Other (please give details) First name(s) Surname Date of birth Gender Your gender doesn t affect the premium. D D M M Y Y Y Y D D M M Y Y Y Y Male Female Male Female Marital status What is your relationship to person 1? Married Living together as partners Divorced Widowed Single Separated Civil partnership Surviving civil partner Married Living together as partners Divorced Widowed Single Separated Civil partnership Surviving civil partner Wife Husband Civil partner Partner/co-habitant Common law spouse Business partner Company Employer Other If Other, please give details Your home address Postcode If you move house while we re processing your application, please contact us once you ve moved to your new address. Page 3 of 13
2 About the people covered continued Person 1 Person 2 In which country are you permanently resident? UK Jersey UK Jersey Guernsey Isle of Man Guernsey Isle of Man Other If Other, please give details Other If Other, please give details In the next six months, will you be moving from the country in which you re permanently resident? If Yes, please give full details. Yes No Yes No Email Phone number Daytime Evening Daytime Evening Page 4 of 13
3 Additional information Page 5 of 13
4 GP details Name of doctor or practice Person 1 Person 2 Address Postcode Phone number If you ve changed GP in the last six months, please give the details of your previous GP in the additional information section on page 5. 5 Premium payment details Is the person paying for the plan the plan owner? If Yes, please go to payment frequency question. Account name Yes No What is the plan payer s relationship to the plan owner(s)? Wife Husband Civil partner Partner/co-habitant Common law spouse Business partner Company Other First name(s) Surname We may need to verify the identity of the person paying for this plan. So that we can do this, please give us their home address and date of birth. Address Postcode Date of birth D D M M Y Y Y Y Payment frequency Monthly Yearly Page 6 of 13
5 Premium payment details continued Payment day Which day would you prefer us to collect your premiums? Please choose between 1st - 28th of each month. Sort Code Account number 6 Start date a) The plan is to start on the date shown D D M M Y Y Y Y b) The plan is to start as soon as we accept it c) To be advised 7 Important notes References to we, us and our refer to the Royal London Mutual Insurance Society Limited (Royal London), which is part of the Royal London Group. The Royal London Group consists of the Royal London Mutual Insurance Society Limited and its subsidiaries, including Royal London Marketing Limited. We may need to share the application information with our agents (such as underwriters, reinsurers, and medical agencies), for the purposes of requesting medical information or arranging examinations. If you re applying for insurance with other companies at the same time as this, by signing the declaration you re agreeing to copies of any medical reports prepared on your behalf being shared between Royal London and these other companies. If, however, another company asks us to provide copies of highly sensitive information (for example HIV test results), we ll ask for your written permission before we do so. We may ask you to contact your doctor if we re waiting for reports we ve asked for. You can ask us for a copy of the key facts, plan details, cover summary or your application form at any time. The plan won t start until we ve assessed and accepted your application, and we ve received a Direct Debit mandate. If you re resident in: the UK, your plan will be governed by the law of England & Wales. Jersey, Guernsey or Isle of Man, your plan will be governed by the law of England and held under Seal; unless otherwise agreed with Royal London. If you ve applied for Unemployment Cover or Waiver of Premium (Unemployment), your contract for those benefits will be provided by UK General Insurance Ltd on behalf of UK General Insurance (Ireland) Ltd. Royal London Marketing Limited will make this insurance available as a cover under the plan on behalf of UK General. Remember you must tell us about any change of personal health, your family s medical history, any occupational change, participation in hazardous pursuits, travel or residence between now and the date the plan starts. If you don t do this, and this affects the terms we would have offered you, your plan may be cancelled and may not pay out in the event of a claim. You can ask us for details of any company we use to assess your application, by writing to us at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. Page 7 of 13
8 Data protection How we use your personal information We, the Royal London Mutual Insurance Society Limited (and our businesses and divisions) may obtain personal information either from you directly, or with your consent, from your approved intermediary or from other sources such as your doctor or an identity authentication agency. We ll use your personal information (including sensitive personal information) for the following purposes: Providing and developing our products and services Improving customer care Verifying your identity and fraud prevention Research and analysis Marketing Legal and regulatory reasons Administering your plan We ll keep your personal information for a reasonable time and we may also share information about you with other companies within the Royal London Group, your approved intermediary, our service providers and agents and with third parties such as auditors, underwriters, reinsurers, medical agencies, identity authentication and fraud prevention agencies, other financial institutions and legal and regulatory bodies. Your personal data may be processed in countries outside the European Economic Area. This processing will be carried out by experienced and reputable organisations and only on terms which safeguard the security of your data and comply with the requirements of the Data Protection Act 1998. We may contact you by mail, phone, fax, email or other electronic messaging either directly or through your approved intermediary with further offers, promotions and information about our products and services that may be of interest to you. By providing us with this information you consent to being contacted by these methods for these purposes. Please tick this box if you don t wish to receive these communications. Plan owner Person 1 Person 2 We may carry out an identity authentication check to verify your identity. This involves checking the details you supply against those held on any databases that may be accessed by the reputable third party company which carries out our checks. This includes information from the electoral register and fraud prevention agencies. We ll use scoring methods to verify your identity. A record of this search will be kept and may be used to help other companies verify your identity. We may also pass information to financial and other organisations involved in money laundering and fraud prevention to protect ourselves and our customers from theft and fraud. If you give us false or inaccurate information and we suspect fraud, we ll record this and share this information with other organisations. We may monitor and record phone calls and retain these for the purposes of training and quality assurance and to ensure that we have an accurate record of your instructions. If you provide us with information about another person, you confirm that they ve appointed you to act for them to consent to the processing of their personal data and that you ve informed them of our identity and the purposes (as set out above) for which their personal data (including sensitive personal data) will be processed. You have the right to ask for a copy of the information that we hold on you, for which we re entitled to charge a small fee. You can ask us to correct any inaccuracies in your information. If you have any questions about how we ll use your personal information, please write to us at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. Page 8 of 13
9 Access to medical reports We may need to obtain a medical report from your current GP or specialist, or from a doctor you ve seen in the past. You have specific rights in relation to medical reports, which are covered in the Access to Medical Reports Act 1988 (also the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991, and the Access to Health Records and Reports Act 1993 (Isle of Man)). Before we ask for such a report, we need your consent, which you can give by signing the declaration in section 9. You can choose not to give your consent, but then we may not be able to continue with your application. This doesn t prevent you from applying to other insurance companies for insurance. We ll let you know if we ask for a report. Under the above Acts, you can choose to see your medical report before it is sent to us. You ll then have 21 days to make arrangements with your doctor to see it. You should indicate below whether you want to see your report. If you don t want to see the report now, you can still contact your doctor later and tell them that you do in fact want to see it. As long as it hasn t already been sent to us, you ll still have 21 days from the time you contact your doctor to make arrangements to see it. If the report has already been sent to us, you re entitled to see a copy of the report at any time during the six months following the date the report was sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date. If you say that you do want to see the report, then it won t be sent to us until: either you ve seen the report or 21 days have passed since we requested the report and the doctor hasn t heard from you. If you see the report, you can withdraw your consent for the doctor showing it to us, or you can ask the doctor to change it if you disagree with it. If the doctor refuses to change it, you can insist that they attach a statement of your views to the report. A doctor may refuse to let you see your report if they feel that seeing it will cause physical or mental harm to you or others. Note: Your doctor is entitled to charge you for supplying you with a copy of the report. The medical report your doctor fills in asks about the following: Your current health any care, medication or treatment you re currently receiving the results of referrals or tests you re waiting for. Any time off work in the last three years Your past health details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultation with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of: malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually worsening) diseases musculoskeletal disease or injury, for example, arthritis, rheumatism, back problems or any other disorder of the joints or muscles anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose contact with reality), stress or fatigue suicidal thoughts or attempts at suicide, or conditions related to drug or alcohol misuse or smoking or chewing tobacco. Details of any biopsies, blood tests, electrocardiograms (heart tests), height, weight if measured in the last two years, urinalyses (tests on urine), x-rays or other investigations Any blood pressure readings in the last three years Any history of disease among your parents or brothers or sisters that you ve told your doctor about. We have asked your doctor not to reveal information about: negative tests for Human Immunodeficiency Virus (HIV), Hepatitis B or C Any sexually-transmitted diseases unless there could be long-term effects on your health, or Predictive genetic test results unless there is a favourable test result which shows that you ve not inherited a condition your family suffers from. The information you and your doctor provide about your health may result in us: Refusing to provide insurance Increasing premiums above standard rates, or Setting premiums at standard rates. If you have any questions about your rights or questions relating to the process of getting, assessing or storing medical information, please write to us at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. Page 9 of 13
9 Declaration Access to medical reports declaration Person 1 and Person 2 should always complete these boxes. Name Person 1 Person 2 Postcode Please only tick this box if you DO want to see your medical report before it s sent to Royal London. Enter plan number here if your financial adviser is sending this page to Royal London as an AMRA declaration for an application submitted online. I ve read the statement in section 9 notifying me of my rights under the Access to Medical Reports (AMRA) legislation, and consent to my doctor providing medical reports to Royal London so that they can deal with my application for a protection plan. Yes I DO want to see my medical report. I understand that it won t be sent to Royal London until I ve seen it, and that they won t be able to make a decision on my application until then. I ve read the statement in section 9 notifying me of my rights under the Access to Medical Reports (AMRA) legislation, and consent to my doctor providing medical reports to Royal London so that they can deal with my application for a protection plan. Yes I DO want to see my medical report. I understand that it won t be sent to Royal London until I ve seen it, and that they won t be able to make a decision on my application until then. Declaration and consent Signature Person 1 Person 2 Date D D M M Y Y Y Y D D M M Y Y Y Y Page 10 of 13
10 Direct Debit details Please complete and return this form to Royal London, 1 Thistle Street, Edinburgh EH2 1DG You must complete this form if: The person, or people, paying for the plan are not the applicant(s). More than one signature is required to authorise payments for the plan. So that we can identify the plan when you return this form, please give us the full name of the person or people covered. Name Person 1 Person 2 Postcode Date of birth D D M M Y Y Y Y D D M M Y Y Y Y Application number The Royal London Mutual Insurance Society Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. The firm is on the Financial Services Register, registration number 117672. It provides life assurance and pensions. Registered in England and Wales number 99064. Registered office: 55 Gracechurch Street, London, EC3V 0RL. Royal London Marketing Limited is authorised and regulated by the Financial Conduct Authority and introduces Royal London s customers to other insurance companies. The firm is on the Financial Services Register, registration number 302391. Registered in England and Wales number 4414137. Registered office: 55 Gracechurch Street, London, EC3V 0RL. 6 7 1 7 5 2 Page 11 of 13
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Royal London 1 Thistle Street, Edinburgh EH2 1DG royallondon.com All literature about products that carry the Royal London brand is available in large print format on request to the Marketing Department at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. All of our printed products are produced on stock which is from FSC certified forests. The Royal London Mutual Insurance Society Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. The firm is on the Financial Services Register, registration number 117672. It provides life assurance and pensions. Registered in England and Wales number 99064. Registered office: 55 Gracechurch Street, London, EC3V 0RL. Royal London Marketing Limited is authorised and regulated by the Financial Conduct Authority and introduces Royal London s customers to other insurance companies. The firm is on the Financial Services Register, registration number 302391. Registered in England and Wales number 4414137. Registered office: 55 Gracechurch Street, London, EC3V 0RL. November 2015