Application/amendment form
|
|
- Morris Hamilton
- 5 years ago
- Views:
Transcription
1 Application/amendment form Bupa Fundamental Health Insurance Switching to Bupa Fundamental Health Insurance Thank you for choosing Bupa. This form should be completed by the intermediary on behalf of your client. Before you begin Please complete this form using BLOCK CAPITALS and BLACK INK Remember to give us as much detail as you can about your client and any family members that they wish to have covered. Your client must ensure that they answer all the questions honestly and to the best of their knowledge. If they don t their policy may be cancelled, or treated as if it never existed, or claims may be rejected or not fully paid. D D ticked the cover option in Section 1 D D included full details of all the family members your client would like to cover D D checked with your client s family members that their details are correct D D remembered to sign and date the form D D made sure you and your client have a copy of this form for your own records D D ensured the direct debit instruction section has been signed by your client Once you have completed this form, please upload this onto the intermediary quote tool or if you are unable to do so, please contact the Consumer Intermediary team on *, option 2. Once we have received and processed your client s application they will receive a welcome pack in the post. *We may record or monitor our calls. For office use only Date application received Name of applicant D D M M Y Y Y Y
2 1. Bupa Fundamental Health Insurance Please tick the relevant boxes to indicate which options your client(s) require. Please note that the choice of scheme and excess level may impact on the premium you pay for the cover. Cover options Full cancer cover NHS Cancer Cover Plus No cancer cover Excess Main applicant/ member Member 2 Member 3 Member 4 Member 5 Excess options (please tick) Hospital Network options Essential Access Extended Choice Extended Choice with Central London Intermediary details Bupa agency number Intermediary name Telephone number address 2. Main applicant details To see how we use your information, please read our privacy notice on page 10. Mr Mrs Miss Ms Other (please list title if other) Surname First name(s) Address Telephone number Mobile number address Postcode Date of birth D D M M Y Y Y Y Sex at birth Male Female Occupation (please note: we will request proof of applicant occupation) If your client would like any members of their family (partner, children etc) to be included in their membership, please go to section 3. If not, go to section 4. 2
3 3. Your client s family s details If your client would like to cover members of their family, please give us their details below. Remember to check with each family member that you have their correct details. Please note that the inclusion of each family member will impact on the premium you pay for the cover. Full name of family member Relationship to you Member 2 Member 3 Member 4 Member 5 Date of birth D D M M Y Y D D M M Y Y D D M M Y Y D D M M Y Y Sex at birth Male Female Male Female Male Female Male Female Occupation (Please note: we may request proof of applicant occupation) What if your client needs to add more family members? If your client would like to cover family members additional to those listed above, please give us their details on a separate sheet of paper. Your client will also need to answer both parts of section 4 for them. 4. Underwriting options (Please tick one box only) Your client may only switch to Bupa Fundamental Health Insurance from their existing policy if they and all persons to be covered have held their policy continuously for 12 months and where their personal medical underwriting remains the same. If they are switching from a less comprehensive policy, we may need further medical evidence. We will apply the same underwriting terms as those your client currently has with their existing insurer. Please provide confirmation of their current underwriting terms. Continued Underwriting terms (this option is only available if your client is currently underwritten with their existing insurer). Current Underwriting terms Full medical underwriting Medical history disregarded Current cover start date D D M M Y Y Y Y Continued Moratorium (this option is only available if your client currently has moratorium underwriting). Current Underwriting terms Fixed moratorium Rolling moratorium Moratorium start date D D M M Y Y Y Y Benefit will not be available for the treatment of any disease, illness or injury (whether the condition was diagnosed or not) for which in the five years before the start date of their existing policy; they have received medication, advise or treatment or they have experienced symptoms. We will pay for the treatment of this condition after two years continuous membership of the Moratorium scheme from the date of joining if the member has not; J J received any medication for, or J J asked for, or received, any medical advice or treatment for, or J J experienced symptoms of that Moratorium condition for a continuous period of two years. 3
4 Calculating your client s No Claims Discount To enable us to calculate your client s No Claims Discount, please answer the following questions How long has the person to be covered been continuously included in any existing or previous health insurance policy? One year Two years Three years Four years Five or more years Main applicant/ member Member 2 Member 3 Member 4 Member 5 When did your client last claim for benefit, if ever, under their existing or previous health insurance policy? (please tick) More than one year ago More than two years ago More than three years ago More than four years ago More than five years ago Never claimed Main applicant/ member Member 2 Member 3 Member 4 Member 5 4
5 5. Medical history part one Please answer each question as it applies for your client and each person named in section 3. (If your client is an existing member and is only adding family members, they do not need to fill out further details or the medical history relating to their own health, only for their family members.) Full name of family member Main member Member 2 Member 3 Member 4 Member 5 (Please tick the relevant box) Yes No Yes No Yes No Yes No Yes No Have you been a UK resident for more than six months? Are you registered with a GP in the UK? Have you been registered with your GP for at least six months? If you are not registered with a GP currently or have not been for at least six months, do you have access to your full medical records in English? (Please note that to continue with your application you must be registered with a UK GP and if under six months, have access to your full medical records in English) If you have answered No to any questions above please provide details Do you play a sport on a professional or semi-professional basis? If Yes, which sport(s)? Please call us for available cover Have you smoked any tobacco products in the last two years? (over 18s only) Additional questions If you tick yes to any of the below questions please provide further details overleaf. Answering yes to any questions above may result in exclusions being applied to the policy. 1. In the last five years has the person to be covered had any form of cancer that is not already excluded on their existing scheme? 2. In the last five years has the person to be covered had a heart or circulatory condition that is not already excluded on their existing scheme (for example, coronary artery disease (angina and heart attacks), stroke, abnormal heart rhythms, blood clots or aneurysms, heart valve disorders, uncontrolled high cholesterol/blood pressure etc? 3. Does the person to be covered have any planned or pending investigations, treatment, surgery, follows ups or therapies for any condition or symptom (this applies whether the treatment is planned privately or under the NHS)? 5
6 5. Medical history part two To help us build a more complete picture of your client (and your client s family s) health, please use the space below to expand on any of the conditions your client answered Yes to in part one. Please give as much specific detail as possible. Failure to do so will result in delays processing your application. Name of member: Question number from part one Please describe the illness or medical problem. If applicable please specify which area of the body is affected, (eg left, right, upper, lower) When did symptoms begin/end? If on-going please leave end date blank Began D D M M Y Y Y Y Ended D D M M Y Y Y Y Treatment (prescribed or otherwise) Outcome of treatment (eg ongoing, complete, recurrent or likely to recur) How many times have you consulted a healthcare professional about this condition or symptom in the past two years? Name of member: Question number from part one Please describe the illness or medical problem. If applicable please specify which area of the body is affected, (eg left, right, upper, lower) When did symptoms begin/end? If on-going please leave end date blank Began D D M M Y Y Y Y Ended D D M M Y Y Y Y Treatment (prescribed or otherwise) Outcome of treatment (eg ongoing, complete, recurrent or likely to recur) How many times have you consulted a healthcare professional about this condition or symptom in the past two years? Name of member: Question number from part one Please describe the illness or medical problem. If applicable please specify which area of the body is affected, (eg left, right, upper, lower) When did symptoms begin/end? If on-going please leave end date blank Began D D M M Y Y Y Y Ended D D M M Y Y Y Y Treatment (prescribed or otherwise) Outcome of treatment (eg ongoing, complete, recurrent or likely to recur) How many times have you consulted a healthcare professional about this condition or symptom in the past two years? 6
7 5. Medical history part two continued To help us build a more complete picture of your client (and your client s family s) health, please use the space below to expand on any of the conditions your client answered Yes to in part one. Please give as much specific detail as possible. Failure to do so will result in delays processing your application. Name of member: Question number from part one Please describe the illness or medical problem. If applicable please specify which area of the body is affected, (eg left, right, upper, lower) When did symptoms begin/end? If on-going please leave end date blank Began D D M M Y Y Y Y Ended D D M M Y Y Y Y Treatment (prescribed or otherwise) Outcome of treatment (eg ongoing, complete, recurrent or likely to recur) How many times have you consulted a healthcare professional for this condition in the past two years? Name of member: Question number from part one Please describe the illness or medical problem. If applicable please specify which area of the body is affected, (eg left, right, upper, lower) When did symptoms begin/end? If on-going please leave end date blank Began D D M M Y Y Y Y Ended D D M M Y Y Y Y Treatment (prescribed or otherwise) Outcome of treatment (eg ongoing, complete, recurrent or likely to recur) How many times have you consulted a healthcare professional for this condition in the past two years? Name of member: Question number from part one Please describe the illness or medical problem. If applicable please specify which area of the body is affected, (eg left, right, upper, lower) When did symptoms begin/end? If on-going please leave end date blank Began D D M M Y Y Y Y Ended D D M M Y Y Y Y Treatment (prescribed or otherwise) Outcome of treatment (eg ongoing, complete, recurrent or likely to recur) How many times have you consulted a healthcare professional for this condition in the past two years? 7
8 6. Paying for your client s cover Subscription quoted Payment is made by monthly direct debit. Please ensure your client completes the Direct Debit instruction on page 11. When would your client(s) like their cover to start? Day Month Year Please note: Although we will try to start your client s cover on the date indicated above, this cannot be guaranteed. Your client s start date will be confirmed on their membership certificate. Please note we will not backdate start dates to a date prior to receipt of the application. 7. Obtaining medical reports from a GP Important: Please read this declaration carefully before signing and dating the completed form. Your client consents to Bupa obtaining a written medical report from their/family member s consultant or general practitioner in order to support their application or claim, made using this form. Your client/client s family members understand that they have rights under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (NI) Order 1991 (the Acts ). The Your rights section below summarises your client/their family members rights under the Acts. Your client and their family members should read this section carefully and if they don t understand any point, they should ask for further information. Your client/client s family members rights 1. They can authorise the disclosure of the doctor s report without asking to see it. The report will then be sent directly to us by the doctor. Should they give their consent to the disclosure of a report without indicating their wish to see it, your client can change their mind by contacting their doctor before the report is sent to us, in which case they will have the opportunity to see the report and ask the doctor to change the report or add their comments before it is sent to us, or withhold their consent for its release. 2. They can give their consent but ask to see the report before it is sent to us. If your client does this they should contact their doctor within 21 days of sending the request to him/her. If they do not contact the doctor within the 21 day period they have authorised them to disclose the report to us directly without further notice to your client. If they do contact their doctor within the 21 day period they must give them their written consent to disclose the report. Your client may ask their doctor to change the report if they think it is misleading. If their doctor refuses, they can insist on adding their own comments to the report before it is sent to us. 3. They can withhold their consent but, if they do, please bear in mind that we may be unable to process your client s request. Whether or not your client indicates that they wish to see the report before it is sent, they have the right to ask their doctor to let them see a copy, provided your client asks him/her within six months of the report having been supplied to us. Your client s doctor is entitled to withhold some or all of the information contained in the report if, in their opinion, this information (a) might cause serious harm to their physical or mental health or that of another person, or (b) it would reveal the identity of another person without their consent (other than that provided by a healthcare professional in their professional capacity in relation to their care). Your client s doctor may charge a fee for providing a medical report, which may be reclaimable from Bupa. Your client/client s family members do (NOT*) wish to see the medical report from their consultant or general practitioner before it is supplied to Bupa. *Delete the word NOT if you wish to see the medical report. 8
9 8. Your legal declaration By submitting this form I the intermediary understand that I am bound by the terms of this legal declaration. Important: Please read this declaration carefully before signing and dating the completed form. I confirm the following: 1. The client has declared that to the best of their knowledge and belief the information given in this form is true, accurate and complete. The client understands that Bupa can end a person s policy or refuse to pay a claim in full or part if there is reasonable evidence that they or a dependant did not take reasonable care when providing any information requested in this form. 2. Where the client has provided information on behalf of any other person to be covered by the policy, I have checked with the client that the information about each other person is also correct before completing this form and the client has confirmed that they have express agreement from each individual to submit this form on their behalf. 3. The client has declared they understand their personal information and that of any other person to be covered by this policy will be processed by Bupa for the purposes set out in Bupa s privacy notice. The client has provided me with confirmation that they have brought Bupa s privacy notice to the attention of any other person who will be covered by the policy. 4. The client has declared they agree to be bound by the terms of this policy (including in respect of those terms that apply to any other person to be covered by this policy). The client has confirmed they understand and agree that English law will apply to the policy. It is essential that the client takes reasonable care to provide full, complete and accurate information when you complete this form. Please be sure to check the entire form. If the client does not provide complete information about themselves or any other person covered under the policy, we will have the right to end their policy, or to refuse to pay all or part of a claim. We recommend that you and the client keep a record of all the information you supply to us in connection with this form, including letters. If you or the client would like a copy of this form, please ask us. This form must be received by us within six weeks of the date of this declaration. Fill in the form with complete up-to-date medical history before you sign and date it. If we do not receive this application form within six weeks of this declaration date, we will require you to submit a new form.. Obtaining medical reports from your GP: The client/client s family members have confirmed that they understand that Bupa may need them to provide a medical report from their GP within the first 24 months of their membership before treatment is authorised The client/client s family members have agreed to Bupa obtaining this information from their GP on their behalf and they understand that Bupa will gain verbal confirmation from them prior to any medical report being requested in this way The client has confirmed that they understand the rights they have in relation to such reports as explained in section 7 The client has confirmed that they have shown this declaration to the proposed dependants on the policy and confirm that they understand that if they need to claim they will be asked on the telephone to confirm their consent to Bupa requesting a medical report on their behalf If the client does not wish Bupa to request medical reports on their behalf in this way, please tick this box Signature Date D D M M Y Y Y Y Your client/client s family members do (NOT*) wish to see the medical report from their consultant or general practitioner before it is supplied to Bupa. *Delete the word NOT if you wish to see the medical report. 9
10 Bupa privacy notice in brief We are committed to protecting your privacy when dealing with your personal information. This privacy notice provides an overview of the information we collect about you, how we use and protect it. It also provides information about your rights. Further details can be found in our Full Privacy Notice available at bupa.co.uk/privacy. If you do not have access to the internet and would like a paper copy of the Full Privacy Notice, please contact the Bupa Privacy team on +44 (0) Alternatively you can the team at dataprotection@bupa.com or write to Bupa Data Protection, Willow House, 4 Pine Trees, Chertsey Lane, Staines-Upon-Thames, Middlesex TW18 3DZ. If you have any questions about how we handle your information, please contact us at dataprotection@bupa.com Information about Bupa In this privacy notice, references to we or us or our are to Bupa. Bupa is registered with the Information Commissioner s Office, registration number Z Bupa is comprised of a number of trading companies, many of which also have their own data protection registrations. For company contact details, visit bupa.co.uk/legal-notices Scope of our privacy notice This privacy notice applies to anyone who interacts with us in relation to our products and services ( you, your ), via any channel (eg , website, telephone, app etc). Ways in which we obtain personal information We obtain personal information from you and from certain third parties (eg those acting on your behalf, like brokers, healthcare providers etc). Where you provide us with information about other individuals, you must ensure that they have seen a copy of this privacy notice and are comfortable with you doing this. Categories of personal information We process two categories of personal information about you and/or, where applicable, your dependants, namely standard personal information (eg information we use to contact you, identify you or manage our relationship with you); and special categories of information (eg health information, information about race, ethnic origin and religion that allows us to tailor your care, and information about crime in connection with screening). Purposes and lawful grounds of our processing personal information We process your personal information for the purposes set out in our Full Privacy Notice, including to administer our relationship with you (including for claims and complaints handling), for research and analysis, to monitor our expectations of performance (including of health providers relevant to you) and in order to protect the rights, property, or safety of Bupa, our customers, or others. The legal ground upon which we process personal information depends on what category of personal information we process. Standard personal information is normally processed by us on the basis that it is necessary for the performance of a contract, our or a third parties legitimate interests or it is required or permitted by applicable law. Marketing and preferences We may use your personal information to send you marketing by post, telephone, social media platforms, and text. We only use your personal information to send you marketing if we have either your consent or a legitimate interest. If you don t want to receive personalised marketing about similar Bupa products and services that we think are relevant to you, please contact us at optmeout@bupa.com or write to Bupa Data Protection, Willow House, 4 Pine Trees, Chertsey Lane, Staines- Upon-Thames, Middlesex TW18 3DZ Processing for Profiling and Automated Decision Making Like many businesses, we sometimes use automation to provide you with a quicker, better, more consistent and fair service, as well as with marketing information we think will be of interest (including discounts on our products and services). This may involve evaluating information about you and, in some limited cases, using technology to provide you with automatic responses or decisions. You can read more about this in our Full Privacy Notice. You have the right to object to direct marketing and profiling relating to direct marketing. You may also have rights to object to other types of profiling and automated decision-making. Further details are available in our Full Privacy Notice. Sharing your information We share your information within the Bupa Group, with relevant policyholders (including your employer if you are covered under a group scheme), with funders commissioning services on your behalf, those acting on your behalf (eg brokers and other intermediaries) and with others who help us provide services to you (eg healthcare providers) or from whom we need information to handle or verify claims or entitlements (eg professional associations). We also share your information in accordance with the law. You can read more about what information may be shared in what circumstances in our Full Privacy Notice. 10
11 Transfers outside of the European Economic Area (EEA) Bupa deals with many international organisations and uses global information systems. As a result, Bupa transfers your personal information to countries outside of the European Economic Area ( EEA ), (the EU member states plus Norway, Liechtenstein and Iceland) for the purposes set out in this privacy policy. How long we retain your personal information Bupa retains your personal information in accordance with retention periods calculated in accordance with the criteria detailed in the Full Privacy Notice available on our website. Your rights You have rights to have access to your information and to ask us to rectify, erase and restrict use of your information. You also have rights to object to your information being used, to ask for the transfer of information you have made available to us, to withdraw consent to the use of your information and not to be subject to automated decision-making which produce legal effects concerning you or similarly significantly affects you. Data Protection Contacts If you have any questions, comments, complaints or suggestions in relation to this notice, or any other concerns about the way in which we process information about you, please contact us at dataprotection@bupa.com You also have a right to make a complaint to your local privacy supervisory authority. Bupa s main establishment is in the UK, where the local supervisory authority is the Information Commissioner, who can be contacted at: Information Commissioner s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF, United Kingdom. Tel: (local rate) or (national rate). 11
12 Direct Debit instruction Instruction to your Bank or Building Society to pay by Direct Debit Please complete the white areas in BLOCK CAPITALS and BLACK INK to instruct your bank to make payments directly from your account. Then return the completed form to: Bupa Insurance Services Limited, Anchorage Quay, Salford Quays M50 3XL Originator Identification Number Name and full postal address of your Bank or Building Society branch To: The Manager Bank or Building Society Address 5. Bupa reference/membership number For Bupa Insurance Services Limited official use only This is not part of the instruction to your Bank or Building Society Note to member: Please complete your member/group name below (if applicable) Postcode 2. Name(s) of account holder(s) 3. Branch sort code 4. Bank or Building Society account number 6. Instruction to your Bank or Building Society Please pay Bupa Insurance Services Limited Direct Debits from the account detailed in this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this instruction may remain with Bupa Insurance Services Limited and, if so, details will be passed electronically to my Bank/Building Society. Signature(s) Date D D M M Y Y Y Y Banks and Building Societies may not accept Direct Debit instructions for some types of account. This guarantee should be detached and retained by the Payer. The Direct Debit Guarantee This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Bupa Insurance Services Limited will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Bupa Insurance Services Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit by Bupa Insurance Services Limited or your bank or building society you are entitled to a full and immediate refund of the amount paid from your bank or building society. If you receive a refund you are not entitled to, you must pay it back when Bupa Insurance Services Limited asks you to. You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. Should you wish to cancel this instruction through Bupa Insurance Services Limited, please call us on You must allow a minimum of seven days before the next payment by Direct Debit is due. We may record or monitor our calls. 12
13 Final checklist Before you return the form have you: DD Ticked the cover option in Section 1 DD DD DD DD Included full details of all the family members your client would like to cover Checked with your client s family members that their details are correct Remembered to sign and date the form. Made sure you and your client have a copy of this form for your own records Upload completed form onto the intermediary quote tool or or if you are unable to do so please contact the Consumer Intermediary team on , option 2 Once we have received and processed the application your client will receive a welcome pack in the post. 13
14 Bupa health insurance is provided by: Bupa Insurance Limited. Registered in England and Wales No Bupa Insurance Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Arranged and administered by: Bupa Insurance Services Limited, which is authorised and regulated by the Financial Conduct Authority. Registered in England and Wales No Registered office: 1 Angel Court, London EC2R 7HJ. Bupa 2018 bupa.co.uk BFD/8563/MAY18 BHF 04074
Application form. Bupa By You. Thank you for choosing Bupa. Before you begin. For office use only. Ex Group Scheme Transfer D D M M Y Y Y Y
Application form Bupa By You Ex Group Scheme Transfer Thank you for choosing Bupa This form should be completed by you, the intermediary on behalf of your client. Please complete this application form
More informationBupa Select. Your application form. Before you begin. Applying to join from another insurance company
Bupa Select Your application form Applying to join from another insurance company Before you begin The Group Secretary must complete the Scheme details and the main applicant must complete Sections 1 to
More informationBupa Select. Your application form. Before you begin. Applying to join from another insurance company
Bupa Select Your application form Applying to join from another insurance company Before you begin The Group Secretary must complete the Scheme details and the main applicant must complete Sections 1 to
More informationDelay, missed departure and catastrophe claim form
Bupa travel insurance Delay, missed departure and catastrophe claim form Please send completed claim forms with supporting documentation to: Bupa Travel Claims, Willow House, Pine Trees, Chertsey Lane,
More informationPersonal effects, baggage, money and legal protection claim form
Bupa travel insurance Personal effects, baggage, money and legal protection claim form Please send completed claim forms with supporting documentation to: Bupa Travel Claims, Willow House, Pine Trees,
More informationMedical expenses and cutting short your trip claim form
Bupa travel insurance Medical expenses and cutting short your trip claim form Bu~ Please send completed claim forms with supporting documentation to: Bupa Travel Claims, Willow House, Pine Trees, Chertsey
More informationTrip cancellation or amendment claim form
Bupa travel insurance Trip cancellation or amendment claim form Please send completed claim forms with supporting documentation to: Bupa Travel Claims, Willow House, Pine Trees, Chertsey Lane, Staines,
More informationBUPA GLOBAL CLAIM FORM
BUPA GLOBAL CLAIM FORM IMPORTANT INFORMATION For quicker handling of your claim, simply log in to your Membersworld account and either complete a digital version of this claim form, or complete the mandatory
More informationTrip cancellation claim form
Trip cancellation claim form Please send completed claim forms with original, not photocopied documents to: Bupa Travel Claims, Willow House, Pine Trees, Chertsey Lane, Staines, Middlesex TW18 3DZ United
More informationComplete your details
Complete your details Bupa By You medical history form bupa.co.uk Before you begin Please complete this form using BLOCK CAPITALS and BLACK INK. It s important you provide us with your medical history.
More informationCash Plan Claim form D D M M Y Y D D M M Y Y. Your membership number. A. Your personal details
Cash Plan Claim form You can now submit cash plan claims to us securely online, at: bupa.co.uk/cash-plan-claims If you d prefer to submit this claim form by post, then before sending you should check your
More informationComplete your details
Complete your details Bupa Healthcare Plan application/amendment form Underwritten Before you begin Please complete this form using BLOCK CAPITALS and BLACK INK. Thank you for choosing Bupa. Before we
More informationSelect Healthcare Plan
Select Healthcare Plan Your application/ amendment form Underwritten Thank you for choosing Bupa. Before we can welcome you and your family member, please complete this application form as fully as possible.
More informationDeclaration and Consent
Declaration and Consent Keeping life colourful You should take reasonable care to answer all the questions honestly and to the best of your knowledge. If you do not answer all of the questions fully and
More informationProvided by Scottish Widows Bank SUMMARY BOX SUMMARY BOX. The interest rate is variable. The current rate is shown in the table below.
E-CASH ISA 3 Provided by Scottish Widows Bank SUMMARY BOX PLEASE READ THIS SUMMARY BOX BEFORE YOU COMPLETE THE APPLICATION AND THEN KEEP IT FOR YOUR RECORDS. DON T RETURN IT WITH THE APPLICATION. This
More informationM&G Adviser reference number
The M&G ISA Application for tax year ending 5 April 20 Y Y KIID MGSL This form: can be used to invest in The M&G ISA for the first time can be used to make an additional subscription to your M&G ISA, and
More informationINSTANT SAVER 2 ACCOUNT
INSTANT SAVER 2 ACCOUNT Provided by Scottish Widows Bank SUMMARY BOX PLEASE READ THIS SUMMARY BOX BEFORE YOU COMPLETE THE APPLICATION AND THEN KEEP IT FOR YOUR RECORDS. DON T RETURN IT WITH THE APPLICATION.
More informationPlease read this section carefully before completing this application form.
Pensions Ill1 ILL HEALTH FORM You will need to complete this application form if you would like to apply for your retirement savings on the grounds of ill health and you have one of the following plans
More information(Including Direct Debit Instruction) For the Collective Retirement Account (CRA)
EMPLOYER PAYER FORM (Including Direct Debit Instruction) For the Collective Retirement Account (CRA) *SFEMP0400F* Application number u if known form purpose: This form must be completed by the employer
More informationPower of Attorney Application to Appoint an Attorney to Operate an Account(s)
Power of Attorney Application to Appoint an Attorney to Operate an Account(s) Please complete this form using black ink and BLOCK CAPITALS and return it together with and any proofs of identity/residency,
More informationINDIVIDUAL STAKEHOLDER PENSION PLAN APPLICATION FORM TO SET UP A NEW PLAN TO RECEIVE ADVISED TOP-UPS
INDIVIDUAL STAKEHOLDER PENSION PLAN APPLICATION FORM TO SET UP A NEW PLAN TO RECEIVE ADVISED TOP-UPS WHEN TO USE THIS FORM This application form is to set up a new Individual Stakeholder Pension Plan into
More informationIncome Protection Plus Application Form
www.pgmutual.co.uk Income Protection Plus Application Form Please note: In order to become a Member you must be residing and working in the UK and working a minimum of 16 hours per week You must have been
More informationFor commission eligibility and FCA product sales data purposes: if you did not provide advice on this sale please tick. FCA number
The M&G ISA Application to transfer your ISA(s) to M&G from another ISA manager KIID MGSL This form can be used to: transfer both previous and current tax year ISA contributions to M&G from another ISA
More informationPRIVATE MEDICAL INSURANCE CORPORATE HEALTHCARE EMPLOYEE APPLICATION FORM
Moratorium underwriting PRIVATE MEDICAL INSURANCE CORPORATE HEALTHCARE EMPLOYEE APPLICATION FORM For plans taken out with VitalityHealth after March 2011. To apply for VitalityHealth membership complete
More informationAny fee charged by the member s GP for providing information for completion of the claim form will not be covered.
TRAVEL COVER CLAIM FORM FILLING IN THIS FORM Please fill in this form if a claim is being made from the Worldwide Travel Cover. Complete this form in black ink and as fully and truthfully as possible.
More informationChild Trust Fund Transfer Application Form
Child Trust Fund Transfer Application Form How to complete this form Please complete this form in BLOCK CAPITALS and in black ink. Mark the boxes with a cross as appropriate. Please do not write on or
More informationISA transfer application form
ISA transfer application form The BMO ISA is provided by BMO Fund Management Limited. This application will transfer your existing ISA(s) into the BMO ISA Transfer Account. You should complete a separate
More informationFP CAF Investment Fund OEIC Application Form
FP CAF Investment Fund OEIC Application Form (to be used only by charitable organisations not constituted as corporate bodies (e.g. not companies, limited liability partnerships etc.)) For completion by
More informationCHANGE OF EMPLOYMENT FORM APPROPRIATE PERSONAL PENSION SCHEME/ PERSONAL PENSION SCHEME
CHANGE OF EMPLOYMENT FORM APPROPRIATE PERSONAL PENSION SCHEME/ PERSONAL PENSION SCHEME SW Policy No. THIS FORM SHOULD BE COMPLETED IF YOU ARE A MEMBER OF THE SCOTTISH WIDOWS APPROPRIATE PERSONAL PENSION
More informationClaim Form Hospitalisation
Claim Form Hospitalisation ACE European Group Limited, A Chubb Company Claims Department PO Box 682 Winchester SO23 5AG T: 0345 841 0059 F: 0141 285 2901 claims@chubb.com Please write in black ink and
More informationHomeInvestor. Application for additional cover under mortgage options. Important notes
HomeInvestor Application for additional cover under mortgage options Important notes This application relates to the mortgage options which are available under, and governed by, the HomeInvestor Provisions
More informationDiscounted Gift Trust
*APDBA0300F* Discounted Gift Trust For use with bare and discretionary versions Part A Application for a Collective Investment Bond to use with a Discounted Gift Trust THIS APPLICATION CANNOT BE SUBMITTED
More informationThe Retirement Account Application form
The Retirement Account Application form You can use this application if: You are not entitled to a Guaranteed Minimum Pension (GMP), a Guaranteed Annuity Rate (GAR) or a Section 9 (2b) rights. If you are
More information3 YEAR FIXED TERM DEPOSIT ACCOUNT
3 YEAR FIXED TERM DEPOSIT ACCOUNT Provided by Scottish Widows Bank SUMMARY BOX PLEASE READ THIS SUMMARY BOX BEFORE YOU COMPLETE THE APPLICATION AND THEN KEEP IT FOR YOUR RECORDS. DON T RETURN IT WITH THE
More informationPERSONAL PENSION (TOP UP PLAN) APPLICATION FORM
PERSONAL PENSION (TOP UP PLAN) APPLICATION FORM CHECKLIST TO BE COMPLETED BY YOUR FINANCIAL ADVISER Have you fully completed your company details on page 2? Yes No Have you completed and enclosed a separate
More informationComplete your details
Complete your details Bupa By You medical history form bupa.co.uk Before you begin Please complete this form using BLOCK CAPITALS and BLACK INK. It s important you provide us with your medical history.
More informationThe Sanlam Portal ISA Application Form
Application under The Sanlam Portal Please note in this Application, we, us means Sanlam Financial Services UK Limited (SFS). In certain instances we use Sanlam Investments and Pensions which is a trading
More informationApplication form / / Pension Annuity. Once you ve completed this form, please return it to: Legal & General Retirement PO Box 809 Cardiff CF24 0YL
Pension Annuity Application form Once you ve completed this form, please return it to: Legal & General Retirement PO Box 809 Cardiff CF24 0YL You will have a quote(s), illustrating the possible benefits
More informationUltraCare Plan Individual & Family Application Form
Pacific Prime International Innovations in International Private Medical Insurance UltraCare Plan Individual & Family Application Form If you have any questions or need any assistance in completing this
More informationCORE INVESTMENTS (PERSONAL PENSION) WITH INCOME RELEASE
65A50 CORE INVESTMENTS (PERSONAL PENSION) WITH INCOME RELEASE Application form Thank you for choosing a Pension Portfolio Plan with Royal London. You ll need to complete this application form to apply
More informationICVC and ISA Application forms
ICVC and ISA Application forms 2017/2018 Form A Form B Form C Form D Application for a 2017/2018 tax year stocks and shares ISA Application to transfer an existing stocks and shares ISA to an Invesco Perpetual
More informationFTSE 100 Tracker Fund ISA Application
FTSE 100 Tracker Fund ISA Application Before completing this application form, please read: The appropriate FTSE 100 Tracker Fund Key Investor Information Document (KIID) and Supplementary Information
More informationTransfer application form
Prudential Personal Pension Scheme (T86) Transfer application form Please use black ink and write in CAPITAL LETTERS or tick 4 as appropriate. Any corrections must be initialled. Please do not use correction
More informationMember application form
14P7 GROUP STAKEHOLDER PENSION PLAN Member application form Thank you for applying for your Retirement Solutions Group Stakeholder Pension Plan. You ll need to complete this application form to apply for
More informationMember application form
14P8 GROUP PERSONAL PENSION PLAN Member application form Thank you for applying for your Retirement Solutions Group Personal Pension Plan. You ll need to complete this application form to apply for your
More informationThank you for choosing a Pension Portfolio Plan with Royal London. You ll need to complete this application form to apply for your plan.
65A55 BENEFICIARY INCOME RELEASE Application form Thank you for choosing a Pension Portfolio Plan with Royal London. You ll need to complete this application form to apply for your plan. 1 Important information
More informationClaim Form Personal Accident / Sickness
ACE European Group Limited, A Chubb Company Claims Department PO Box 682 Winchester SO23 5AG T: 0345 841 0059 F: 0141 285 2901 claims@chubb.com Claim Form Personal Accident / Sickness Please write in black
More informationThank you for downloading this information.
Thank you for downloading this information. For more information, advice or for a free quote, please contact our global head office at the address below who will redirect you to a regional office located
More informationFP WHEB Asset Management Funds ISA Transfer Application Form Class A Shares
FP WHEB Asset Management Funds ISA Transfer Application Form Class A Shares For completion by the introducing intermediary (if applicable) Advised Investment* Non-advised Investment* *Please tick as appropriate
More informationClaim Form Cancellation / Curtailment
Claim Form Cancellation / Curtailment Chubb European Group Limited Claims Department PO Box 682 Winchester SO23 5AG T: 0345 841 0059 F: 0141 285 2901 uk.claims@chubb.com Please write in black ink and use
More information*PPPPEN01* Amending your Personal Pension/ Personal Retirement. change of status and reinstatement. A Member s personal details and eligibility
Financial adviser stamp Amending your Personal Pension/ Personal Retirement Account change of status and reinstatement Please enter your business postcode Agency reference number *PPPPEN01* Please use
More informationISAs, UNIT TRUSTS, OEICs ISA TRANSFERS APPLICATION FORM. 2018/2019
LEGAL & GENERAL (UNIT TRUST MANAGERS) LIMITED ISAs, UNIT TRUSTS, OEICs ISA TRANSFERS APPLICATION FORM. 2018/2019 Please ensure you ve read the current version of the following documents before you make
More informationAnnuity Death Benefit Payment Authority
Annuity Death Benefit Payment Authority To be completed by the individual(s) acting on behalf of the estate Please complete in Black Ink The death benefits due* under the policy are: Please tick appropriate
More informationINDIVIDUAL SAVINGS ACCOUNT (ISA) APPLICATION FORM FOR OFFICE USE ONLY S B. Introducer Code (if different from above) Branch Sort Code.
INDIVIDUAL SAVINGS ACCOUNT (ISA) APPLICATION FORM FOR OFFICE USE ONLY Agency Number Referral Type Vantive Lead ID Introducer Code (if different from above) Campaign Code Branch Sort Code SB Code S B Share
More informationICVC and ISA Application forms
ICVC and ISA Application forms 2018/2019 Form A Form B Form C Form D Application for a 2018/2019 tax year stocks and shares ISA Application to transfer an existing stocks and shares ISA to an Invesco Perpetual
More informationFor commission eligibility and FCA product sales data purposes: if you did not provide advice on this sale please tick
M&G OEIC funds Application to invest a lump sum KIID Important Information: Before investing, you should read an up-to-date version of the Key Investor Information Documents (KIIDs) for the fund(s) in
More informationDeferred Member s Transfer Request Form to a Personal Pension Scheme May 18
www.spfo.org.uk Deferred Member s Transfer Request Form to a Personal Pension Scheme May 18 Deferred Member's Transfer Request Form Request for Payment of Cash Equivalent Transfer Value to a Personal Pension
More informationIf you do not have a National Insurance number, please tick here
ISA application form The BMO ISA is provided by BMO Fund Management Limited. This form is an offer to enter into an agreement that covers your transactions with BMO Fund Management Limited (trading as
More informationFP Foresight OEIC ISA Transfer Application Form
FP Foresight OEIC ISA Transfer Application Form For completion by the introducing intermediary (if applicable) Advised Investment* Non-advised Investment* *Please tick as appropriate 1. Personal Details
More informationBMI Card application form
Please note that we will be unable to process your BMI Card application if you do not provide a signature in the credit agreement section on page 7. BMI Card application form CREDIT CARD AGREEMENT REGULATED
More informationSwitch on application form
65A53 CORE INVESTMENTS (PERSONAL PENSION) WITH INCOME RELEASE Switch on application form You ll need to complete this application form to switch on the Income Release facility within your Royal London
More informationBupa Fundamental Health Insurance. Your Bupa membership guide. Essential information explaining your cover. Please retain.
Bupa Fundamental Health Insurance Your Bupa membership guide Essential information explaining your cover. Please retain. About this guide Welcome to your Bupa Fundamental Health Insurance membership guide.
More informationSelected Investment Funds (SIF) Plan and SIF Individual Savings Account (ISA) New Investment Application Form
Selected Investment Funds (SIF) Plan and SIF Individual Savings Account (ISA) New Investment Application Form Notes on completing this Application Form This Application Form should only be used for the
More informationCanInvest Select Account Application for a new policy
Your Account will be set-up on the basis of your Personal Example reference number quoted here: P O B This reference number is on the bottom left hand corner of the Personal Example. Applications without
More information14/15. tax year. Application forms 2014/2015
Application forms 2014/2015 Form A Form B Form C Form D Form E Form F Form G Application for a 2014/2015 tax year stocks and shares ISA Application for a 2014/2015 tax year cash ISA Application to transfer
More informationTitle Surname Forename(s) D.O.B. 1% AMC. Please select if you do not have an Agent or where your Agent is not paid trail commission.
K Fundsmith Equity Fund Please complete this form in ink using BLOCK CAPITALS. Return the form to your adviser or Fundsmith LLP, PO Box 10846, Chelmsford, CM99 2BW. The Key Investor Information Document
More informationInvestment ISA (Stocks and Shares) 2014/2015 Tax Year
Investment ISA (Stocks and Shares) 2014/2015 Tax Year IMPORTANT: Please read all these documents before you sign the declaration CommShare Ltd Terms of Business Cofunds Platform Key Information Document
More informationDeferred Member s Transfer Request Form to a Scheme that was contracted in
www.spfo.org.uk Deferred Member s Transfer Request Form to a Scheme that was contracted in May 18 Deferred Member's Transfer Request Form Request for Payment of Cash Equivalent Transfer Value to an Occupational
More informationUNIT TRUST. Application Form
UNIT TRUST Application Form UNIT TRUST APPLICATION FORM Please keep this page for your records. The Direct Debit Guarantee This Guarantee is offered by all banks and building societies that accept instructions
More informationLifestyle security plan data capture form
An introduction to Dentists Provident Lifestyle security plan data capture form For applicants in the UK 1 Dentists Provident Important notes: before completing this form General Before you complete this
More informationStakeholder Pension Plan
Application form Who this form is for 0817 When we refer to Standard Life we mean Standard Life Assurance Limited. This form is for people who want to become members of the Standard Life Stakeholder Pension
More informationCORE INVESTMENTS (PERSONAL PENSION) WITH INCOME RELEASE
65A50 CORE INVESTMENTS (PERSONAL PENSION) WITH INCOME RELEASE Application form Thank you for choosing a Pension Portfolio Plan with Royal London. You ll need to complete this application form to apply
More informationFirst Notice of Claim for Illness or Injury
How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents required Section A: Statement of claimant
More informationApplication for a life assurance plan on the life of another person
Application for a life assurance plan on the life of another person Before completing this form, please read this information carefully. This form is for use where the applicant wishes to take out a plan
More informationApplication Form for the Curtis Banks SIPP
Application Form for the Curtis Banks SIPP This application form is a legally binding document between you (the applicant), Curtis Banks Limited and Colston Trustees Limited. Please complete all relevant
More informationProtected Housa ISA Application Form 2014/2015
Protected Housa ISA Application Form 2014/2015 Protected Housa ISA Application Form 2014/15 Please complete this application form using BLOCK CAPITALS and in black ink. Please complete all sections and
More informationCanada Life Group Critical Illness
CLAIM FORM Claims procedures Please note that in order to satisfy a claim, the insured person s illness must meet the definition for the relevant critical illness described within the Policy Conditions.
More informationAegon ISA transfer application form
For customers Aegon Platform Aegon ISA transfer application form In this form, Aegon means Cofunds Limited. Use this form to transfer investments from an ISA held with another ISA manager to an Aegon ISA.
More informationRBS International OneCard Cardholder Application Form
RBS International OneCard Cardholder Application Form Guidelines for completing this form On screen Use the tab key to move between the relevant fields Do not use the return or enter keys Please refer
More informationINHERITABLE ISA ALLOWANCE TRANSFER OF UNITS FORM
INVESTOR PORTFOLIO SERVICE INHERITABLE ISA ALLOWANCE TRANSFER OF UNITS FORM Use this form to transfer funds from your deceased spouse/civil partner s holding, to a stocks and shares ISA with IPS. FOR ADVISER
More informationTransfer application form
F&C Investment Trust ISA Transfer application form This application form is an offer to enter into an agreement with F&C Management Limited ( F&C ) for an F&C Investment Trust ISA. You can use this form
More informationTB Evenlode Investment Funds ICVC OEIC Investment
TB Evenlode Investment Funds ICVC OEIC Investment Account Opening and Initial Investment Application Form For private investor use only This application form is for private investors who do not already
More informationISA TRANSFER APPLICATION FORM.
INVESTOR PORTFOLIO SERVICE SELF DIRECTED TAX YEAR 2017/2018 ISA TRANSFER APPLICATION FORM. Use this form to transfer an existing stocks and shares or cash ISA from another ISA manager to a stocks and shares
More informationREED INSURANCE LIMITED - CRITICAL ILLNESS CLAIM FORM REED REWARDS MEMBER
REED INSURANCE LIMITED - CRITICAL ILLNESS CLAIM FORM REED REWARDS MEMBER Instructions Please answer all questions accurately with full disclosure of all relevant information. Please return the completed
More informationGroup Personal Pension Flex
Application Form (For employed individuals) Who this form is for When we refer to Standard Life we mean Standard Life Assurance Limited This form is for employees who wish to join a Group Personal Pension
More informationInheritable ISA allowance - transfer of inherited investments from an Aegon ISA
For customers Aegon Platform Inheritable ISA allowance - transfer of inherited investments from an Aegon ISA In this form, Aegon means Cofunds Limited. Before completing this form You must have received
More informationAegon General Investment Account re-registration application form
For customers Aegon Platform Aegon General Investment Account re-registration application form In this form, Aegon means Cofunds Limited. Use this form to transfer funds into an Aegon General Investment
More informationSCOTTISH WIDOWS ANNUITY
SCOTTISH WIDOWS ANNUITY APPLICATION FORM FOR INTERNAL USE SW Policy No. Scottish Widows Quotation No. This application is for the purchase of a Scottish Widows Annuity. The minimum amount we will accept
More informationClaim form - Travel. This document contains fillable form fields. It is recommended you download the file to fill in your information.
Claim form - Travel Contact us for more information: Chubb European Group Limited Claims Department PO Box 682 Winchester SO23 5AG O +44 345 841 0059 F +44 141 285 2901 uk.claims@chubb.com This document
More informationEMPLOYEE APPLICATION FORM LOCAL AUTHORITY AVC FOR OFFICE USE ONLY. Agency Number. Referral Type. Introducer Code. Vantive Lead ID
EMPLOYEE APPLICATION FORM LOCAL AUTHORITY AVC Agency Number FOR OFFICE USE ONLY Referral Type Vantive Lead ID Introducer Code (if different from above) Campaign Code SB Code S B Branch Sort Code Please
More informationPay4Sure Claim Form. How to complete this claim form
Pay4Sure Claim Form Please read carefully Pay4Sure Claim Form How to complete this claim form Please make sure all sections are fully completed and all documents sent together. Incomplete claim forms or
More informationAdditional contribution application form
65A6 CORE INVESTMENTS (PERSONAL PENSION) Additional application form You ll need to complete this application form to apply an additional to your Pension Portfolio Plan with Royal London. 1 Important information
More informationFundZone ISA Stocks & Shares Transfer (cash)
FundZone ISA Stocks & Shares Transfer (cash) Application Form Who this form is for This form is for existing customers who wish to transfer a Stocks & Shares ISA in cash from another ISA Manager to Standard
More informationINDIVIDUAL STAKEHOLDER PENSION PLAN TRANSFER APPLICATION FORM FOR OFFICE USE ONLY. Campaign Code. Agency Code
INDIVIDUAL STAKEHOLDER PENSION PLAN TRANSFER APPLICATION FORM Campaign Code FOR OFFICE USE ONLY Agency Code IMPORTANT INFORMATION Warning: You must not make false statements when filling in this application;
More informationProtected Housa ISA Transfer Form 2013/2014
Protected Housa ISA Transfer Form 2013/2014 Protected Housa ISA Transfer Form 2013/14 Please complete this form using BLOCK CAPITALS and in black ink. Please complete all sections and sign and date the
More informationSun Life Assurance Company of Canada (U.K.) Limited. Customer Data Protection Notice
Sun Life Assurance Company of Canada (U.K.) Limited Customer Data Protection Notice Protecting your privacy We are committed to protecting and respecting your privacy. This notice tells you more about
More informationGroup Personal Pension
Application Form (For employed or self-employed individuals) Who this form is for When we refer to Standard Life we mean Standard Life Assurance Limited This form is for employees, or self-employed individuals
More informationPo/ic} sutv1,;,v1,ar} ClientChoice Plus. Effective from 1 January 2017
Po/ic} sutv1,;,v1,ar} ClientChoice Plus Effective from 1 January 2017 Bu This policy summary contains key information about Bupa ClientChoice Plus. You should read this carefully and keep it in a safe
More informationPERSONAL ACCIDENT CLAIM FORM
APPENDIX E Completion Notes PERSONAL ACCIDENT CLAIM FORM 1. If a claimant is unable to claim personally, the claim form may be completed on his/her behalf. 2. A claim must be submitted within a reasonable
More informationFidelity Personal Pension Top up form (for making a transfer or single/regular payments)
Fidelity Personal Pension Top up form (for making a transfer or single/regular payments) With this form you can: set up a regular payment into an existing plan make a single payment into an existing plan
More information