Group Protection - Medical Declaration

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Coleen Melton
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1 Group Protection - Medical Declaration For members of Group Protection Policies to Aviva Life & Pensions UK Limited ( Aviva ) Group Life & Group Income Protection Please note carefully Failure to disclose all material facts as part of your membership in a Group Protection policy, could mean we are unable to pay a claim, we could restrict or cancel your cover and you may encounter difficulty in trying to purchase insurance elsewhere. Material facts are details that we need to know so we can assess your membership of the policy. Material facts could include medical history, smoking history and details of occupation, travel and pastimes or previous insurance claims. If you are in any doubt as the whether certain facts are material, you should tell us about them anyway. You must also tell us about any changes to the information you give us up until your cover commences. In accordance with the Disability Act 2005, you should not tell us the results of any genetic tests which you have had. Please advise us if someone has completed this form on your behalf and the reasons as to why. If completing by hand use BLOCK CAPITALS and BLACK INK. 1. Employer Details Policy Number Policy / Company Name 2. Your Personal Details Title Forename(s) Surname Gender: Male Female Marital Status Date of birth D D / M M / Y Y Y Y Address Eircode Telephone number (including area code) Your telephone number is required in case we need to contact you at a convenient time for you (between 8am and 6pm weekdays). Address 3. Your Occupation and Travel a) What is your current occupation? Please provide full details of your duties What are your contracted hours per week? What hours do you normally work per week? b) During the last 5 years, have you spent more than 90 days in total in Africa, the Caribbean or Thailand? If yes, please provide full details of exact location(s), frequency of trips, duration and expected travel in the future. c) During the last 2 years, have you spent more than 90 days outside of Ireland or the UK? If yes, please provide details of this travel along with any intended or likely travel of this nature in the future. Please include countries visited, Regions/Cities visited, frequency and duration of visits in days. 1

2 4. Hazardous Pursuits Do you or are you likely to take part in any hazardous activities or pursuits, fly other than as a fare-paying passenger, participate in rock climbing or mountaineering, caving, pot holing, sub aqua diving, ocean yachting, horse riding (other than private hacking), motor sports or racing of any kind, winter sports or any extreme sports? Please note we do not need to know about indoor bouldering/climbing, one-off track days, or on-piste skiing. If your answer is yes, someone from our Medical Underwriting team will contact you separately for further information. 5. Medical and Health questions Material Fact & Genetic Testing Material facts are details that we need to know so we can assess applications for cover and claims for benefits. Material facts could include medical history, smoking history and details of occupation, travel and pastimes. If you do not tell us about material facts when you apply for this cover or at the claims stage, this might mean that the contract could be cancelled without premiums being returned, that we don t pay a claim and you may encounter difficulty trying to purchase insurance elsewhere. If you are in any doubt as to whether certain facts are material, you should tell us about them anyway. You must also tell us about any changes to the information you give us up until the cover commences. In accordance with the Disability Act 2005, you should not tell us the results of any genetic tests which you have had. Name & Address of your usual doctor who holds your medical records. Medical Details 1a) What is your height? ft ins or mtrs cms b) What is your weight? st lbs or kilos c) Other than pregnancy, have you gained or lost more than 1 stone in weight in the last 12 months? If so, please provide the reason and your previous weight st lbs or kilos Reason 2a) How many alcoholic drinks do you consume per week? Pints of beer Glasses of wine Measure of spirits b) How many times per week on average do you drink alcohol? c) Have you ever been advised by your doctor or other medical practitioner to drink less alcohol? If yes, please provide full details 3) (a) If you have smoked any cigarettes in the last 12 months, please state the average number of cigarettes smoked per day? (If you have not smoked cigarettes within the last 12 months, enter 0) Number of cigarettes per day (b) Have you used any other tobacco products in the last 12 months? 4) Many people need to take drugs to treat a medical condition. But, have you taken any recreational drugs such as cocaine, cannabis, ecstasy or heroin or any non-prescribed drugs in the last 5 years? 5) Have you ever tested positive for HIV/AIDS or Hepatitis B or C, or are you waiting on the result of such a test? If you have answered yes to Q4 or Q5, please give full details including dates or if you would rather tell us in confidence, you can send the information via to chief.medical.officer.group.protection@aviva.com 2

3 6. Health Questions Please tick yes or no to all the questions. If you answered yes to any of the questions, please provide full details by completing the Additional information section at the end of the application. Have you ever had, suffered from or been diagnosed with any of the following: 1) Insomnia, stress, anxiety, tension, depression, personality disorder, eating disorder, mental illness or breakdown, suicide attempt or psychiatric condition that has resulted in you taking medication, taking time off work or consulting your doctor or other medical practitioner or counsellor? 2) Stroke, brain haemorrhage, brain injury or transient ischaemic attacks? 3) Heart disease or disorder (including heart murmur, heart attack, cardiomyopathy, angina, heart valve disorder, palpitations, rheumatic fever, abnormality of your heart, arteries or veins)? 4) Multiple sclerosis, optic or retrobulbar neuritis, paralysis, epilepsy, cerebral palsy, Parkinson s disease, Alzheimer s disease, dementia, tremor, seizures or any other disease of the central nervous system (the brain, spinal cord and nerves) not already mentioned? 5) Tingling, loss of feeling or sensation, numbness, paraesthesia (pins and needles) for which you have consulted a doctor or received medical advice or treatment? 6) Cancer, leukaemia, Hodgkin s disease, lymphoma, brain tumour, spinal tumour or any other tumour? 7) Diabetes or sugar in the urine (glycosuria)? 9) Have you ever been diagnosed as having, or been treated for, raised blood pressure? 10) Have you been diagnosed as having raised cholesterol, been treated for it or ever had a cholesterol reading greater than 6.5? Have you, in the last five years, had or suffered from or been diagnosed with any of the following: 11) Back pain, slipped disc, sciatica, or any other back, neck or shoulder complaint? 12) Persistent or recurrent tiredness, fatigue, myalgic encephalomyelitis (M.E.), post viral fatigue or chronic fatigue syndrome? 13) Chest pain, irregular heart beat or any other pulse abnormality? 14) Anaemia, or any blood disorder or abnormalities. 15) Dizziness, vertigo, fainting, blackouts or fits? 16) Disorder of the eyes, including blurred or double vision or defective sight (but not short or long sight which is corrected by lenses)? 17) A lump, growth of any kind, cyst, mole or freckle that has required treatment? Or are you intending to seek any medical advice in connection with a tumour, cyst, lump or growth of any kind: or any mole or freckle that has bled, become painful, changed colour or increased in size, whether seen by a doctor or not? 18) Kidney, bladder, prostate disorder or any other disorder of the genito-urinary system (including blood or protein in the urine)? 19) Any disorder of the digestive system, liver, stomach, pancreas or bowel (including gastric or duodenal ulcer, hepatitis, colitis or Crohn s disease)? 20) Psoriasis, skin disorder or allergy? 21) Rheumatic, arthritic or muscular complaints including joint pains, knee pain, gout or a repetitive strain syndrome/injury? 22) Tinnitus or any disease, disorder or abnormality affecting your ears, hearing or balance? 3

4 23) Asthma, bronchitis, emphysema or any disease, disorder or abnormality affecting your lungs? 24) In the last 5 years have you consulted any doctor, psychiatrist or other medical adviser for anything NOT already mentioned? 25) Are you suffering from any other symptoms, disease, disorder or disability? 26) Are you waiting for any medical or surgical consultations, results, tests or investigations? 27) Within the last 2 years have you been absent from work due to illness or injury for more than four weeks at a time? If, please provide full details. 7. Family History Have either of your natural parents, or any of your brothers or sisters (including half brothers/sisters), suffered or died from, any of the following conditions before the age of 65? Raised Blood Pressure, Stroke, Angina, Heart Attack, Cancer, Diabetes, Polycystic Kidney Disease, Polyposis Coli, Huntington s disease, Hypertrophic Obstructive Cardiomyopathy, Alzheimer s disease, Motor Neurone Disease, Haemochromatosis, Multiple Sclerosis, Familial Hyperlipidaemia, Muscular Dystrophy, Parkinson s disease, or any hereditary disease of which you are aware? If yes, please fill in the sections below for relatives who are or were affected by any of the illnesses shown. If your relative had cancer, tell us which part of their body was first affected, if known to you. Relationship Medical condition Age at diagnosis Cause of death Age at death 8. Claim History In the last 5 years, have you claimed for a medical condition under a Specified Illness or Income Protection policy? If yes, then please provide the following information: Type of insurance: Date of claim: Reason for the claim: Did you take any time off work? If yes, how long? 4

5 9. Additional Information If any of the medical questions have been answered yes and more detail is relevant, please use this section. Briefly describe the symptoms suffered and areas affected (for example left arm, right eye etc.) Please state the question number along with the condition Question. Question. Question. Date you first suffered from the symptoms How frequently have you suffered from the symptoms? Date you last suffered from the symptoms What investigations were undertaken and what were the results? Please provide most recent readings (e.g. latest blood pressure, cholesterol or PSA readings) or Blood test results if known If cancer or a growth, do you know if it was benign or malignant? Also the type of tumour and staging if known What medical advice, medication or treatment were you given? Who gave you this advice - please provide their name and address? What time off work has been taken? If time off work was necessary, please advise exact period and dates Has a full recovery been made with no residual effects? Have you been fully discharged from the care of all medical practitioners? Are you able to follow your occupation without restriction or has any aspect had to change to accommodate your condition? Any other comments - if you have any specialist reports relating to the conditions above, it may assist the processing of your declaration, if you attach a copy of the latest report. Please now check you have completed ALL questions, sign and date the form and return this to our address below or via at GPM@aviva.com. 5

6 10. How we use your details DATA PROTECTION USE OF INFORMATION NOTICE The information you provide about yourself and about third parties will be held by Aviva Life & Pensions UK Limited (the data controller) and may be used, stored and processed by Aviva Group companies (together, we, us or our ), our commercial partners, authorised agents/service providers and/or successors, on computer systems and/or in paper files for the following purposes: (a) to provide and administer financial services/products requested by you; (b) to comply with applicable legal or regulatory obligations; and (c) for other legitimate business interests of Aviva Life & Pensions UK Limited, including marketing that you have permitted and protection against non-disclosure of material facts and fraud. In connection with these purposes, information may be shared, both inside and outside the European Economic Area, with our other insurance and financial services companies including those within the Aviva Group and third parties such as reinsurance companies, medical practitioners, Insurance Ireland, trustees/administrators and sponsoring employers of pension plans, other insurance and financial services companies, our service providers such as those to whom we outsource certain business operations, professional advisers, private investigators who may be instructed to investigate a claim, reputable external agencies and as required by law. To assist in preventing, detecting and/or protecting our customers and ourselves from theft and fraud, we may also use your information to make searches of our records. If you give us false information or fail to disclose information and we suspect fraud, we will record this. In the event of your application not proceeding or your policy ceasing, information provided in connection with such may be retained for as long as is permitted by law and may be shared as outlined above where applicable. Where sensitive personal data, for example data relating to your physical or mental health, is provided by you or on your behalf, access to and disclosure of this information will be restricted to that necessary for the purposes set out above, in particular for administering contracts of insurance/products requested by you (including underwriting, processing, claims handling, reinsurance, protection against non-disclosure and fraud prevention). We may record your telephone calls for quality assurance purposes. You may request, in writing, a copy of your information held by us. Please write to The Data Protection Officer, at our branch, Aviva Life & Pensions Ireland, One Park Place, Hatch Street, Dublin 2, together with payment of the applicable fee (currently 6.35). You may be asked to prove your identity before your request is met. If you believe there may be inaccuracies identified in the information held about you, then you can contact The Data Protection Officer to have such corrected, to block certain uses or object to the processing of your personal data. You confirm, by signing the declaration on the following page, that you have fully explained to each person whose information has been provided to us by you in connection with this policy, the purposes and use for which that information has been provided and how the information may be used, in the same detail as set out in this form and that each person has explicitly consented to such. Marketing We would like to use your details to provide you with information about other financial or insurance products, services and special offers either from us or other Aviva Group companies, or products, services and special offers which any member of the Aviva Group may arrange with a third party. Your details may be used for this purpose (for up to 12 months) after your policy has ceased. Your details may be used for this purpose if the policy does not proceed, for up to 12 months after the date of the quotation. Please tick here if you do not wish to receive such information from us. Your choice will not affect any of the services we provide to you, now or in the future. By submitting this application or if you have any other communication with Aviva Life & Pensions UK Limited through or in relation to its products and services, you acknowledge the foregoing and consent to the processing of the personal data as indicated above. In particular you acknowledge and explicitly consent to the arrangements in relation to sensitive personal data as indicated. 6

7 11. Declaration Declaration of Client I the life to be insured, irrevocably authorise and request any doctor or other person who may be in possession of, or hereafter acquire, any information regarding my health up to the present time to disclose such information (with the exception of the results of genetic tests) to Aviva Life & Pensions UK Limited. I agree that this authority shall remain in force after my death as well as prior thereto. I consent to Aviva Life & Pensions UK Limited seeking information from any insurance company to which an application has been made on my life for Life, Accident, Specified Illness, Sickness or Disability cover and I authorise the giving of such information (with the exception of the results of genetic tests). I declare that the information on the application form and all other information furnished by me and/or on my behalf (whether in my handwriting, any other hard copy form, by any electronic means or verbally) in relation to my application for cover are true and complete. I understand that: 1. All parts of this application must be fully completed and any alterations initialled by the signatory 2. Failure to provide true and complete information may mean that the contract could be cancelled without premiums being returned, or, that Aviva don t pay a claim. 3. Any changes to the answers given, before the policy comes into force, must be notified immediately to Aviva Life & Pensions UK Limited at their branch office, Aviva Life & Pensions UK, One Park Place, Hatch Street, Dublin This application and declaration together with any representations made by the life to be insured to a medical practitioner acting for Aviva will be the basis of the contract. 5. If a premium is tendered or a direct debit order is signed no binding contract is created until Aviva Life & Pensions UK Limited confirms cover, the policy document is issued and the first premium is paid. 6. Aviva s processes may involve electronic means including, but not limited to, data entered on-line, the recording of information provided by me during a medical examination or a telephone interview, the capturing of my signature on an electronic device or the use of electronic signatures. I also agree to the use by Aviva Life & Pensions UK Limited of my personal data and where applicable, sensitive personal data, as indicated in the Data Protection Use of Information tice. Signature Please sign and date Print Name Today s date / / 7

8 Retirement Investments Insurance H Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is authorised by the Prudential Regulation Authority in the UK and is regulated by the Central Bank of Ireland for conduct of business rules. Aviva Life & Pensions UK Limited, trading as Aviva Life & Pensions Ireland, is also regulated in the UK: by the Prudential Regulation Authority for prudential rules and, to a limited extent, by the Financial Conduct Authority for applicable UK conduct rules. Registered Branch Office in Ireland ( ) at One Park Place, Hatch Street, Dublin 2. Tel (01) Web Registered in England ( ) at Wellington Row, York, YO90 1WR

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