FLEXIBLE SAVINGS PLAN FLEXIBLE SA

Transcription

1 FLEXIBLE SAVINGS FLEXIBLE SAVINGS PLAN PLAN Application Form

2 Flexible Savings Plan Important Information All the information that you provide will be shared with all parties to this application. We are able to provide literature and communications in alternative formats. If you would like this document in braille or large print, please contact your LV= Financial Adviser or us. Please read the Key Features document, Policy Conditions and Your guide to how we manage our With Profits fund before completing and returning this application in the envelope provided. If you need any help completing this application, please contact your LV= Financial Adviser or call us free on am 8pm Monday to Friday and 8am 4pm Saturday. For Textphone: first dial Calls may be recorded and/or monitored for training and audit purposes. Please write clearly, in BLOCK CAPITALS, using black ink. Your details The minimum age for the person/people insured is 17, and the maximum age is 74. For joint plans the plan will be cashed in on the second death. First plan owner Second plan owner (if applicable) Title Mr/Mrs/Miss/Ms/Dr/Other First Name(s) Surname Title Mr/Mrs/Miss/Ms/Dr/Other First Name(s) Surname Telephone Tel (including area code) Work Tel (including area code) Best time to call Telephone Tel (including area code) Work Tel (including area code) Best time to call Note: By supplying an address, I agree to you contacting me by with information about other products and services. address address Date of Birth / / (DD/MM/YYYY) Date of Birth / / (DD/MM/YYYY) Gender Male Female Gender Male Female Are you an existing member of Liverpool Victoria Are you an existing member of Liverpool Victoria Friendly Society Limited? Friendly Society Limited? Yes No Yes No Have you had advice from a Financial Adviser on this product? Yes No 2

3 Details Of Person/People Insured (Only If Different From The Plan Owner(s)) The minimum age for the person/people insured is 17, and the maximum age is 74. For joint plans the plan will be cashed-in on the second death. First person insured Title Mr/Mrs/Miss/Ms/Dr/Other First Name(s) Surname Second person insured (if applicable) Title Mr/Mrs/Miss/Ms/Dr/Other First Name(s) Surname Telephone No. Daytime Telephone No. Evening Telephone No. Daytime Telephone No. Evening Date of Birth / / (DD/MM/YYYY) Date of Birth / / (DD/MM/YYYY) Gender Male Female Gender Male Female Relationship to plan owner(s) Relationship to plan owner(s) Your Investment New Plan How much would you like to invest? (In multiples of 1) Minimum 25 per month or 300 per year. Premium frequency Monthly* Yearly* New plans are set up as a cluster of 10 identical policies. * by direct debit (if you make regular monthly or yearly payments). For a new plan, please complete the instruction, but do not detach. by cheque (if you make regular yearly or lump sum payments). Please make your personal cheque payable (in sterling) to Liverpool Victoria Friendly Society Limited followed by the initial and surname of the owner, e.g LVFS Ltd. J. Smith. If you are paying by a building society cheque please make sure that the building society has endorsed the cheque with your name and account number. Otherwise you ll need to send us verification of the account the money is coming from, which will slow down your application. How long you d like to save for Years Min term of 10 years, max term 30 years, maximum age at end of 84. Where premiums are paid by direct debit our normal practice is that the start date of your plan will be the date we collect the first premium, based on your chosen day of the month for payment. On what day of the month would you like to make your direct debit payment (1st to 28th only) Increases to your regular premiums are payable at the same frequency and on the same day of the month as existing premiums Existing Plan Top Up Additional premiums* (Minimum 5 a month or 60 a year) Additional lump sums (Minimum 500) Please state existing plan number(s) if known 3

4 Waiver of Premium Option If this is an application for an increase to an existing plan, waiver of premium can only be selected if you selected it at the outset, and must be for the same person who has this cover currently. This section needs to be completed for new applications and increases to existing plans. This option is only available to people insured under age 55 and ends at age 65 exactly. For joint applications, waiver of premium is only available to the first person insured. Do you require Waiver of Premium? Yes No Questions for those applying for waiver of premium In joint applications this is always the first person insured. If the person insured (or, in joint cases, the first person insured) can answer No to all of the statements below and sign the declaration then they will qualify for waiver of premium. You may still qualify if you answer Yes to any of the statements below. Please provide full details on the further details section, or on a separate sheet of paper. If you are the person insured (or in joint life cases, the first person insured) please answer the questions below and then read and sign the declaration. n Have you consulted a medical specialist/consultant or received treatment at a hospital or clinic (other than for a minor ailment, such as colds or flu) in the last year, or have you such an appointment pending? Yes No n In the last 3 years, have you suffered from: anxiety, depression or any psychiatric disorder Yes No any disease/disorder of the back or joints Yes No any illness or injury that has prevented you from working for a period of 2 weeks or more? Yes No n Have you had any application for sickness or accident insurance declined, postponed or accepted on other than standard terms? Yes No n In the last five years, have you drunk more than 30 units of alcohol each week on a regular basis? (1 glass of wine (175ml) = 2 units, 1 pint standard beer/lager = 2 units, 1 measure of spirit = 1 units). Yes No n Does your occupation involve: working at heights, underground, offshore or the use of explosives or other hazardous substances residence in under-developed or third world countries, travel to politically unstable countries or war zones? Yes No n Do you participate in any hazardous pursuits? For example mountaineering, motorsport, diving to depths greater than 30m, aviation (other than as a passenger in a commercially licensed aircraft) Yes No 4 Further Details If you answered Yes to any of the above questions, please give further details relating to each question in the spaces below. Wherever possible we will accept your application on the basis of the information you provide in your application form so please give full details on a separate sheet if necessary. Signature (First person insured) Date / / (DD/MM/YYYY) N.B. Where the person insured section has not been completed (i.e. you are the plan owner and the person insured) the first plan owner should sign.

5 Money Laundering Prevention Requirements By law, all financial institutions have to make checks on certain types of investments to help protect against crime. So that we can do this, please answer the questions below. If you don t answer all the questions it may take us longer to set up your plan. Employment Status (e.g. employed, self employed, unemployed etc.) If Employed: name of your employer: of your employer: First plan owner Second plan owner (if applicable) Your job title (or occupation if you are self employed): Your current gross annual salary/earnings If you are investing a lump sum: please tell us the source of the lump sum to be invested in this plan e.g. inheritance, divorce settlement, property sale etc. Important Notes Access to medical reports We may need to get medical reports to support your application. Before we can ask any doctor that you have consulted to fill in a report, we need your permission under the Access to Medical Reports Act Your rights under the act are as follows. You do not need to give your permission, but if you do not, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance. You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to keep the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us. If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date. If you think that any part of the report is not correct or is misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him or her to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others. The medical report your doctor fills in asks about the following: n Your current health. n any care, medication or treatment you are currently receiving. n the results of referrals or tests you are waiting for. n Any time off work in the last three years. n Your past health. n Details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultations with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of: n malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually worsening) diseases; n musculoskeletal disease or injury, for example, arthritis, rheumatism, back problems or any other disorder of the joints or muscles; n anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose contact with reality), stress or fatigue. n suicidal thoughts or attempts at suicide; or 5

6 n conditions related to drug or alcohol misuse or smoking or chewing tobacco. n 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. n any blood pressure readings in the last three years. n Any history of disease among your parents or brothers or sisters that you have told your doctor about. We have asked your doctor not to reveal information about: n negative tests for HIV, hepatitis B or C; n any sexually-transmitted diseases unless there could be long-term effects on your health; or n predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from. The information you and your doctor provide about your health may result in us: n refusing to provide insurance; n increasing premiums above standard rates; or n setting premiums at standard rates. If you have any questions about your rights under the act or questions relating to the process of getting, assessing or storing medical information, please write to: Liverpool Victoria Friendly Society Limited, County Gates, Bournemouth, BH1 2NF. Your Declaration To: Liverpool Victoria Friendly Society Limited (LV=): I apply for a Flexible Savings Plan (or for a premium increase and/or lump sum top up to my existing plan) and declare or agree that: n I know that LV= will not assume risk for the proposed plan until this application has been underwritten and accepted and the first premium paid. n I agree to you asking any doctor I have consulted about my physical or mental health to provide medical information so you may assess my application. You may gather relevant information from other insurers about any other applications for life, critical illness, sickness, disability, accident or private medical insurance that I have applied for. I authorise those asked to provide medical information when they see a copy of this consent form. n I am a resident the UK (excludes Channel Islands and Isle of Man). n I agree that to the best of my knowledge and belief, the information contained in this application is true and shall form the basis of the proposed contract. n I agree that LV= can use any sensitive information I provide, such as health and medical information, to process my application and for the ongoing management of my policy. This information may be passed on to: n my GP n any medical practitioner and/or health care professional acting for LV= n reinsurers or any other insurer I ve applied and given consent to n my financial adviser n any trustee or assignee of the policy (where the policy is assigned) n any associated company of LV= n LV= may use information provided to process my application and manage my plan. The information may be kept electronically or on paper file for as long as the application is being considered, while the plan is active and for an appropriate length of time after that. n LV= may use information given to make searches about me at credit reference agencies that hold my information (such as from the electoral roll). The agencies check my identity and will keep records of these searches, even if my application doesn t go ahead. I understand that LV= may use scoring methods to check my identity and may ask me for supporting documents. We ll keep your information and add it to our marketing databases even if you don t take out a plan with us. We may use it to keep your records up to date, for business analysis and market research. We may also use it to let you know by post, phone, and electronic methods about products and services we think may interest you. We may pass your details to other carefully selected organisations, but only for these purposes. 6

7 If you don t want to receive marketing information, please tick this box Subject to payment of a fee, if you d like us to send you a copy of the personal information we hold about you please write to: CCA Department, LV=, County Gates, Bournemouth, BH1 2NF. For more information about the LV= group of companies go to n If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies to prevent fraud and money laundering. n Further details explaining how the information held by fraud prevention agencies may be used can be obtained by writing to GFC, LV=, County Gates, Bournemouth BH1 2NF. Alternatively, you can visit our website, lv.com, or call us on I confirm that LV= advised me to read the Key Features document, Plan Conditions, Your guide to how we manage our With Profits fund. I have read the Important notes and Declaration and information relating to my rights under the Access to Medical Reports Act. I agree that by signing below I am bound by this section. I don t want to see the report before it is sent to the company (please tick) I do want to see the report before it is sent to the company (please tick) First plan owner Second plan owner (if applicable) Signature Signature Date / / (DD/MM/YYYY) Date / / (DD/MM/YYYY) First person insured (if different from above) Second person insured (if different from above) Signature Signature Date / / (DD/MM/YYYY) Date / / (DD/MM/YYYY) Copies of this completed application form and the terms and conditions are available on request. Direct Debit For Premiums For A New Plan Please complete this direct debit so we can automatically collect your premiums from your bank account when premiums are due. Do not detach from application. Please see the direct debit Guarantee in the enclosed leaflet. For increases to existing plans, we will use the direct debit instruction you have already completed to collect your increased premiums. Instruction to your Bank or Building Society to pay by Direct Debits Please fill in the whole form and send it to: LV= County Gates, Bournemouth BH1 2NF 1. Name and full postal address of your Bank or Building Society To: The Manager Bank or Building Society 2. Name(s) of account holder(s) 3. Branch sort code (from the top right hand corner of your cheque) Service user number 4. Bank or Building Society account No. 5. For completion by LV= 6. Instruction to your Bank or Building Society Please pay Liverpool Victoria Friendly Society 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 Liverpool Victoria Friendly Society Limited and if so details will be passed electronically to my Bank/Building Society. Signature 8 Signature 8 Date Banks and Building Societies may not accept Direct Debit Instructions for some types of accounts. 7

8 For office use only Serial Number Zone/Department Representative responsible for the sale Introducer responsible for the sale Observer for the sale Campaign Reference No Fact Find No (if applicable) Personal ID Introducers Account Number Observers Personal ID Quotation ref: (if known) Cheque Amount You can get this and other documents from us in Braille or large print by contacting us. Liverpool Victoria Friendly Society Limited, County Gates, Bournemouth BH1 2NF. LV= and Liverpool Victoria are registered trade marks of Liverpool Victoria Friendly Society Limited (LVFS) and LV= and LV= Liverpool Victoria are trading styles of the Liverpool Victoria group of companies. LVFS is authorised and regulated by the Financial Services Authority register number LVFS is a member of the ABI, AFM and ILAG. Registered address: County Gates, Bournemouth BH1 2NF. Tel: /12 8