Quotation Acceptance Application Form (QAAF)

Transcription

1 Quotation Acceptance Application Form (QAAF) Section B - Group Income Protection To accept your Group Income Protection quotation(s), please complete this section (section B) of the QAAF. How to complete Section B Please ensure that you fully complete all parts of the questions within this section. Please answer all questions in BLOCK CAPITALS, ticking boxes or circling where appropriate. If you have insufficient space, please provide supplementary information as an attachment. If you are accepting quotes for more than one of a Group Income Protection policy, a Capital Option policy, a Pay Direct policy or Dual Benefit policy each will require a separate form. This form should be completed and returned to Unum before the Commencement Date of the policy(ies) or within 30 days of the Commencement Date if conditional cover is provided. NOTE: This section must be accompanied by Section A - All Products. page 1 of 5 Section B - Group Income Protection UP891B 01/2015

2 Section B - Group Income Protection 1. Scheme Name Scheme Name 2. Eligibility Definition Please provide a definition of eligibility upon which the quotation reference is based. Please indicate if a different description of eligibility applies for separate categories of employee. If you wish to accept more than 4, please photocopy this page and complete the additional details. Tick against which of the following applies: a) Eligibility i) All employees (including working directors) ii) All employees (including working directors) who are members of the employer s pension scheme iii) All working directors iv) All equity partners v) Other and variations (please specify) b) Qualification i) Length of Service to be completed by the employee before they are eligible for the benefit months months months months ii) State minimum age of entry (e.g. 16, 18, 21) iii) State maximum age of entry (e.g. 55, 59, 64) iv) Other and variations (please specify) page 2 of 5

3 2. Eligibility Definition Continued c) Entry i) When does an eligible employee who meets the eligibility conditions become a member: (please tick Daily or Annual) Daily Annual Closed (specify date closed) 3. Earnings Definition Please provide a definition of earnings upon which the accepted quotation reference is based. Please indicate if a different description of earnings applies for separate categories of employee. If there are more than 4 categories of employee, please photocopy this page and complete additional details. Tick against which of the following applies: a) Definition i) Basic annual salary ii) Gross earnings in the previous 12 months ++ iii) P60 earnings in the previous tax year ++ iv) Basic annual salary plus fluctuating emoluments averaged over the last 3 years v) Basic annual salary plus fluctuating emoluments received in the last 12 months ++ vi) Non-PAYE taxed (e.g. Equity partners) - average annual net taxable earnings received in the previous 3 years vii) Other and variations (please specify) page 3 of 5

4 3. Earnings Definition Continued b) Changes i) For benefit purposes, a change in a member s earnings takes effect Immediately At next Policy Accounting Date ++ note that fluctuating emoluments are limited to 20% of basic annual salary as they are not being averaged over the last 3 years. c) TUPE Transfer Please confirm if any of the categories of membership contain members who are eligible as part of a TUPE Transfer. Scheme/Registered Employer* transferred from Date of Transfer (if known) *as detailed on Companies House 4. No Worse Terms Details In order to apply No Worse Terms in respect of members benefits we require details of the previous insurer s free cover limit and details of the benefit on risk at the date of the transfer for all members whose benefit is above Unum s quoted Free Cover Limit OR whose benefit is below this quoted Free Cover Limit but is subject to adverse terms. If this does not apply for any of the current scheme members, please indicate by ticking the box in the table below. If there are current members for whom you wish us to apply No Worse Terms, please provide these additional details by completing the enclosed No Worse Terms Details form. Please note that if incomplete or insufficient information is provided this may impact our ability to maintain previously insured benefits and could also delay the issue of the invoice. Product Unum Quoted Free Cover Limit Previous Insurer s Free Cover Limit If none - please tick page 4 of 5

5 4. No Worse Terms Details Form Proposal Number Product Member s Name Date of Birth Benefit on Risk at Date of Transfer Loading % Above what benefit loading applied ( ) Benefit Restriction ( ) Standard Terms/ Ordinary Rates (please tick) Exclusions (exact wording required) Please tick if you are providing a Once & Done decision from previous Insurer* Please note that if incomplete or insufficient information is provided this may impact our ability to maintain previously insured benefits and could also delay the issue of the invoice. * for Unum to apply a Once & Done decision a copy of the Previous Insurer s decision letter detailing the treatment of benefits is required (please enclose with this form to avoid delay) and also the scheme must satisfy Unum s criteria for Once & Done (see UP1580). page 5 of 5