PROTECTION PERSONAL INCOME PROTECTION APPLICATION Adviser s Name: Agency No.: Please tick (3) where appropriate Please ensure that all questions are answered to prevent any delay in the assessment of your application. This application form along with a recorded Tele-interview will form the basis of your contract. The person to be covered will be contacted by telephone by our Tele-interview provider to complete the application in full. For further details on this procedure please refer to the Tele-interview Explained section of this form. 1. Person to be covered Title: Mr Mrs Ms Other Surname: First name: Address: Date of Birth: Sex: Male Female PPS Number: Occupation: Please ensure you check the Occupational Guide to see if the occupation is eligible for Income Protection. Smoker: Yes No 2. Arranging your Tele-interview To speed up the processing of your application we strongly recommend you arrange the Tele-interview prior to submitting the application to us as this will avoid unnecessary delays in processing your application. This Tele-interview will be recorded. Contact Number(s) for Tele-interview: Mobile: Home: Work: Preferred Contact Time for Tele-interview: Morning Afternoon Evening You may contact our Tele-interview provider on freephone 1800 805395 to arrange a suitable time for your Tele-interview. You will be given a reference number to record in the field below: Tele-interview reference number: If you are not in a position to arrange a Tele-interview at this stage we will pass on your personal details to our Tele-interview provider who will then contact you to arrange a suitable appointment. Please note that this will likely result in your application taking longer to process. Page 1 of 8
3. Cover details Income Protection Amount*: E *75% of gross annual earned income less state illness benefit if applicable and any income that will continue in the event of a disability, subject to an overall max of E175,000 p.a. Expiry Age : Between 55 and 65. Please ensure the expiry age is eligible for the person to be covered s occupation type Deferred Period: 8 wks 13 wks 26 wks 52 wks Indexation: Yes No Confirmed Income Option : Yes No If this option is chosen, proof of income will be required before the policy goes on risk. 4. Payment details Premium: Note: In addition to the Premium, a Government levy (currently 1% of the premium paid) will be collected on each premium due date Preferred Policy Start Date: As soon as possible To be advised Frequency: Every Year Every 6 months Every 3 months Every month If you are paying yearly premiums do you wish to pay by cheque? or Direct Debit? 5. Collection of underwriting information If you proceed with this application, the resulting policy will be based on the information you tell us - in this application form, - in any questionnaire completed by you or by a medical examiner and signed by you and - in any Tele-interview you complete. If you complete a Tele-interview it will be recorded and you will be sent a transcript of the Tele-interview for you to check and keep for your records. Failure to disclose all material facts, in this application, any questionnaire signed by you and in any Tele-interview you complete, could render your contract void. Material facts are those, which an insurer would regard as likely to influence the assessment and acceptance of a proposal for insurance. If you are in doubt as to whether certain facts are material, such facts should be disclosed. We may not necessarily contact your doctor(s). Even if we do, you must still disclose all material facts. We may ask you to have a medical examination with your own doctor or an independent doctor. If this is required we will notify you in writing. Material Facts Exemption in Relation to Genetic Tests You are not required to disclose any genetic tests you may have had and we will not have regard to any genetic tests which may come into our possession. You are however required to provide us with full details (other than genetic tests) in answer to all the health and lifestyle questions including full medical details about your family history. Doctor Details 1. a) Please give the name and address of your usual doctor? b) Have you changed your doctor in the last year? Yes No If Yes, please give the name and address of your previous doctor Page 2 of 8
6. Employment and financial details 1. Have you recently submitted or do you intend to submit an application for life cover and or critical illness Yes No cover to New Ireland Assurance? If yes, please give details. 2. Do you currently have existing Income Protection cover with New Ireland Assurance or any other Life Office? Yes No If Yes, please advise the following: Name of Insurance Company: Annual Benefit Amount: 2 Will this cover be cancelled on issue of this policy Yes No 3. Would you receive an income from your employment if you were unable to work due to an illness or injury? Yes No If Yes, please state for how many weeks this income is payable: wks 4. In relation to your employment status, are you: Employed Self Employed Share Holding Director a) If you are Employed, please state your annual gross salary* in the last tax year 2 * Annual personal earned income before tax in the last year including any regular overtime, commission & bonuses b) If you are Self Employed or a Share Holding Director, please state the following: Your annual gross income* in the last 3 consecutive tax years *Annual Personal Earned Income before tax in the last complete tax year 20 2 20 2 20 2 Number of employees working for you (including sub contractors): if applicable If the Confirmed Income Option is chosen the following proof of income is required: Employed A copy of the three previous months salary slips and a copy of the previous years P60. Self Employed A copy of the three previous years Notice of Assessments along with a copy of related Company Accounts. Share Holding Directors A copy of the three previous years P60s/Notice of Assessments along with a copy of related Company Accounts. If you are self- employed or have been operating your own business for less than one year then your requested benefit level may be reduced or you may not be eligible for the Confirmed Income Option. Important Note The Confirmed Income Option is only available when satisfactory financial evidence is provided before the policy goes on risk. Page 3 of 8
7. Declaration of receipt of disclosure information and policy replacement n Please ensure you complete this section before signing this proposal for assurance. n Declaration under Regulation 6(3) of the Life Assurance (Provision of Information) Regulations, 2001. n WARNING: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance intermediary. Declaration of Insurer or Intermediary I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the Policy Owner, as stated in Section 1 of the Application, have been provided with the information specified in Schedule 1 to those Regulations and that I have advised the client as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction, and of possible financial loss as a result of such replacement. @ Insurer/ Intermediary Signature: Date: Person to be covered I confirm that I have received in writing the information specified in the above declaration. @ Signature: Date: 8. Declaration/Data Protection Consent A. I declare: 1. that in this application I have disclosed all material facts; and 2. I understand that in any questionnaire signed by me and in the Tele-interview I must disclose all material facts; and 3. that to the best of my knowledge, all statements made on this application form whether in my hand writing or dictated by me are true and complete. B. I consent to you seeking: 1. any medical information now or in the event of a claim from any doctor who has at any time attended me; 2. any information from any life insurer to which a proposal has been made on my life; and I authorise the giving of such information to you. C. I agree to the following: 1. all of the statements made on this application form and other statements made by me in writing and/or in the Tele-interview in connection with this application shall form the basis of the contract between you and me. D. I understand that: 1. the proposed contract will not come into force until New Ireland Assurance has accepted me for cover and issued a policy document and I have made the first premium payment; and 2. if I do not pay the first premium, the contract will not be valid even if you send me a policy document. 3. any changes to the statements in - this application, - any questionnaire signed by me and - any Tele-interview I complete before the proposed contract comes into force, must be notified in writing to New Ireland Assurance. 4. if my proposal is declined or if I am offered insurance on special terms then, whether or not my application proceeds, this fact will be noted on a central registry, administered by the Irish Insurance Federation, and may be shared with other insurance companies as a protection against non-disclosure of material facts. I understand that in the event of my application not proceeding, information provided in connection with my application will be retained by New Ireland Assurance for a period of six years to facilitate any future application by me and as a protection against non-disclosure of material facts. E. I confirm that I: have had the meaning of disability, the benefit available under the policy and the reductions that will be applied to the benefit where there are payments from other sources fully explained to me and that I understand and accept these provisions. Page 4 of 8
8. Declaration/Data Protection Consent (continued) I understand and consent that New Ireland and its duly authorised agents may hold and use the Information on computer file, in any other dematerialised form or in written hard copy on its own behalf and may use or pass the Information to third parties for regulatory, administration, customer care and service purposes. n I agree that New Ireland or a duly authorised agent of New Ireland may contact me in person, by phone, or by letter if it considers that my financial planning arrangements need to be reviewed or my level of cover needs to be revised. n I agree that the Information may be held and used by New Ireland for Marketing purposes. Yes Yes No No I understand that I may write to advise New Ireland to cease to hold and use the Information for Marketing purposes at any time. Information means any information including medical and non-medical given by me or on my behalf in connection with this application or any further information which may be given at a later stage either in writing, by email, at a meeting or over the telephone. Marketing means direct marketing and cross-selling of the services and/or products provided by New Ireland or arranged by New Ireland with a third party. @ Person to be covered: Date: Page 5 of 8
9. Tele-interview explained Your Guide to Tele-interviews: Thank you for your application for insurance with New Ireland Assurance. To process your application as smoothly and as quickly as possible, we will arrange for a specialist nurse to telephone you and interview you about your health. You do not have to do anything within the next few days. Our specialist provider will contact you by telephone to arrange the interview. If you are not free to answer the questions when called, he/she will be happy to arrange a more suitable time. Please note that all calls will be recorded. What is a Tele-interview? A Tele-interview is an interview conducted over the telephone by a nurse. The interview will gather details of your health and medical history. All Tele-interviewers are experienced nurses, so you can rest assured that the interview will be conducted in a confidential and professional manner. A series of questions about your health, lifestyle and your immediate family medical history will be asked, and the interview takes at least 30 minutes. Why are you being interviewed? To offer New Ireland Assurance customers the best possible terms for their insurance, it is essential that a clear understanding of your present state of health and any conditions you may have suffered in the past is obtained. This information is used in our risk assessment, prior to considering your insurance cover. Please accept our assurances that the information you provide will be treated in the strictest confidence, and used only in the assessment of your application or in the event of a claim What do I need to prepare? To prepare for your interview, please take some time to gather the following information and have this to hand when you receive the call: Any medication you are currently taking (including the name and dosage). Any past or present medical condition suffered, (other than very minor aliments such as the common cold.) Any tests or investigations, e.g. blood pressure, cholesterol tests. It would be helpful if you phone your GP or whoever did these tests, to get the results. Details of any serious condition, such as cancer, heart attack, stroke, suffered by a member of your immediate family (your mother, father, brothers or sisters, or half brothers and sisters.) We will ask for your height and weight. If you do not know your weight, please try and weigh yourself prior to the interview. If you are not sure whether something is important, then it is best to mention it. The nurse will assist you with any questions you may have. How will you be contacted? If you have given us preferred times, then we will try and reach you at these times. If you are called at an inconvenient moment, please ask to be called again at a more suitable time. If you have not been contacted within three days, or you have been away or out of touch, please phone your Financial Adviser. The nurses are able to undertake interviews from 9am to 9pm Monday to Thursday, 9am to 5pm on Fridays, 10am to 4pm on Saturdays. It is important that you are able to speak freely and have the time to spare to complete the interview. It is better not to conduct the interview over a mobile phone, but if this is your preference, we will do so. We will not complete an interview if you are driving. Unfortunately, your application for insurance cannot be processed until the interview has taken place. Why is it important I provide the right information? The recorded interview and your application form shall form the basis of the contract between you and New Ireland Assurance. All the questions should be answered fully and honestly, as failure to do so could invalidate your policy and any future claims. What happens after the interview? You will be sent a copy of the interview report for you to check, ensuring that the information is complete and accurate. Although a little time consuming it is in your best interest to undertake this task with all due care. If you need to change or add anything to the interview report, then please make any such amendment, then sign and return to us, in the freepost envelope provided. Should you have any general questions relating to your application, New Ireland Assurance can be contacted on Tel 1850 200 318*, Monday to Friday, 8.00am to 6.00pm. To monitor the ongoing quality of the service we provide, your call may be recorded. *Calls are charged at local rates. For quality and training purposes incoming and outgoing calls may be recorded. Call charges may vary depending on your service provider. Page 6 of 8
10. Direct debit mandate Note: Instructions can only be accepted to charge direct debit to a Current or similar account. To the Manager: Bank Address Comhlucht Na héireann um Árachas c.p.t. New Ireland Assurance Company plc. 11-12 Dawson Street, Dublin 2. I/We authorise you until further notice in writing to charge to my/our account with you unspecified amounts which may be debited thereto at the instance of New Ireland Assurance Company plc. by direct debit. Bank Sort Code: - - Name of Account to be debited: Bank Account No.: @ Signed: Date: Policy No.: Originator s No.: / Originator s Ref.: 9 9 9 3 6 8 Page 7 of 8
New Ireland Assurance Company plc., 11-12 Dawson Street, Dublin 2. T: (01) 617 2000 F: (01) 617 2800. E: info@newireland.ie W: www.newireland.ie A Member of New Ireland Group. New Ireland Assurance Company plc is regulated by the Financial Regulator. 301450 V1/08/09 Page 8 of 8