Quotation Acceptance Application Form (QAAF)

Transcription

1 Quotation Acceptance Application Form (QAAF) How to complete this QAAF Please ensure that you fully complete all parts of the questions within this section (section A) and relevant product sections. 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. This form must be completed, signed by the client and returned to Unum before the Commencement of the policy(ies) or within 30 days of the Commencement if conditional cover is provided. We reserve the right to amend our terms if any information provided on this form is different to that which was used to produce our illustration. If any information provided to produce the accepted quote has changed or it was incorrect, it may affect the terms quoted. If information provided is incomplete or incorrect it may prejudice the payment of any claims. Contents checklist Tick when completed Section A - All Products To accept your quotation(s), you must complete this section (section A) of the QAAF. Section B - Group Income Protection (including Capital Option, Pay Direct and Dual Benefit) To accept your Group Income Protection quotation(s), please complete section B of the QAAF. Section C - Group Life (Registered) including Channel Islands and Isle of Man Policies To accept your Group Life (Registered) quotation(s), please complete section C of the QAAF. Section D - Dependants Pension (Registered) including Channel Islands and Isle of Man Policies To accept your Dependants Pension (Registered) quotation(s), please complete section D of the QAAF. Section E - Group Life (Non-registered) To accept your Supplementary Relevant Life or Excepted Group Life quotation(s), please complete section E of the QAAF. Section F - Critical Illness To accept your Critical Illness quotation(s), please complete section F of the QAAF. NOTE: You must complete section A and relevant product sections. unum.co.uk Unum Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Registered in England We monitor telephone conversations and communications from time to time for the purposes of training and in the interests of continually improving the quality of service we provide. Copyright Unum Limited 2013 page 1 of 8 Registered office: Milton Court, Dorking, Surrey RH4 3LZ TEL FAX UP891A 01/2015

2 Section A - All Products 1. Employer Details Business name Registered Number (if applicable) Registered address Postcode Organisational type - Please tick Private Limited Company (LTD) Public Limited Company (PLC) Partnership Limited Liability Partnership (LLP) Specify other Business address (if different from above) Postcode Exact nature of employer s business Name and natures of business for all associated or subsidiary companies included in any of the cover (please provide details on a separate sheet if necessary) Registered Number Company Name Nature of Business 2. Policy Details Group Income Protection Group Income Protection - Capital Option Group Income Protection - Pay Direct Group Income Protection - Dual Benefit Group Life (Registered) Dependants Pension (Registered) Group Life (Non-registered) Group Life for Channel Islands and Isle of Man Group Critical Illness Voluntary Group Critical Illness Other Quotation Reference Quote Basis (e.g. 1,2,3) Rate % or Premium (SP Costed) Start Is the quotation data to be used at inception Yes/No Where quotation data is NOT to be used at inception, please attach the inception data when returning the QAAF.* *If the data is not currently available, this must be provided within 30 days of the signed QAAF being returned or it will be necessary to produce the inception account based on the quatation data. page 2 of 8

3 3. Flexible Benefits Are these policies part of a flexible benefits arrangement? Yes No Implementation date 4. Payment Details and Policy Accounting Payment method* Annually by Cheque Monthly by Direct Debit Annually by Direct Debit Other, please specify Policy Accounting (the date with effect from which the premiums due for the next policy accounting period are calculated usually but not restricted to be policy anniversary date) *Dual Benefit payment method must be by Direct Debit. (date)/ (month) 5. Declaration and Signature Unum The information you provide will be put on our database and used by Unum Limited who is the data controller, in making decisions about the provision of cover and servicing your relationship with us. It will also be used for the purposes of identity verification, fraud prevention, audit, debt collection and claim verification. We may conduct, or have conducted on our behalf, checks with external agents in connection with this application, when dealing with the policy applied for, or to validate any claim. We or our agent may ask you for more information, or carry out further checks and searches when assessing your application, or at any time during the life of your policy/product for the purposes of fraud prevention and claim verification. To help improve our service and in the interests of security, we may monitor and/or record your telephone calls with us. Declaration I/We declare that these statements, together with the information provided to produce the accepted quotation, are true and complete. It is understood that no claim for benefit can be considered which occurred prior to the dates on which cover commences with Unum. This application for insurance is made subject to Unum s usual terms and conditions, and shall form the basis for the contract. It is understood that any cover will only be considered for eligible employees who are Actively at Work, where applicable, in their normal occupation at inception or any date of subsequent increase in benefit. I/We consent to Unum seeking information from any other insurance office and authorise the giving of such information. The Policyholder/Employer authorised signatory (to be completed in all cases): Signed Name (please print) Position/Job Title page 3 of 8

4 5. Declaration and Signature continued Unum Life Assurance Master Plan (A) If using the Unum Life Assurance Master Plan (A) each participating employer (other than the Employer) with life cover must sign below. Participating Employer authorised signatory: Signed Name (please print) Business name in full Position/Job Title Please photocopy this page for additional participating employers to sign and complete details. Trustees Assurance If using your own Registered scheme the trustee(s) must sign below. Please photocopy this page for additional trustees to sign and complete details. Where the trustee is a corporate body, the duly authorised official(s) of that body sign. With individual trustees, each of them or those individuals that are authorised to sign for all of the trustees. Trustee/Trustee authorised signatory: Signed Name (please print) Position/Job Title Please photocopy this page for additional trustees to sign and complete details. page 4 of 8

5 6. Customer Verification This section of the form will allow us to assess whether the necessary Customer Verification checks have been made to comply with the Money Laundering Regulations Unum will accept an intermediary s own Customer Verification Form (or equivalent) provided it meets our minimum standard requirements. This section must be completed by the intermediary and returned to Unum before the first premium or deposit premium (if applicable) is paid. i) Will the Policyholder be paying the Quoted Premium for the quotations you wish to accept? Yes No If NO: please submit a further copy of the Customer Verification Form (UP 778) available from in respect of the third party who is paying the premium If NO: What is the relationship between Policyholder and third party premium payer? ii) Is the applicant a UK public limited company? Yes No If YES: Name of stock exchange of check iii) Is the applicant an entity regulated by the Prudential Regulation Authority or the Financial Conduct Authority? Yes No If Yes, PRA/FCA Registration Number: of check: If you have answered YES to questions ii) or iii) and supplied the information requested, please go to the Intermediary Declaration in section 8 of this form, otherwise complete EITHER (A) Company Search sections (i) or (ii) OR (B) Other Means of Verification of Business Name and Business Address sections (i) and (ii) or sections (i) and (iii) on page 5 of this form. A. Company Search i) I have performed a company search using the WebCheck service on the Companies House website at and confirm that the Company Name and Registered office address match exactly the details provided in section 1 of this form. Yes No OR of Companies House check of Incorporation Company number Country of origin ii) I have performed a recognised organisational search and confirm that the Business Name and Business Address match exactly the details provided in section 1 of this form. Yes No If YES, please provide the name of the recognised search organisation used (e.g. Dunn and Bradstreet, One Source): Name page 5 of 8

6 6. Customer Verification continued B. Other Means of Verification of Business Name and Business Address i) We will accept the following to verify Proof of business name - Please tick: Partnership Agreement (details required: reference number, where held, date of agreement) Copy of latest report and accounts (details required: reference number, name of accountant, date of issue) Certificate of Trade (details required: reference number, name of issuer, date of issue) Lawyer s/accountant s letter confirming documents have been submitted to the relevant companies registry (details required: reference number, name of firm & referee, date of issue) Insert details required to evidence verification of business name: AND ii) We will accept the following to verify Proof of business address : I have visited my client s business premises Yes No of visit: Confirmation that business premises were entered Yes No OR iii) We will also accept one of the following to verify Proof of business address (please tick): Most recent mortgage statement showing current address (details required: name of lender, date of issue) Current Local Authority Tax Bill (details required: name of authority, date of issue) HMRC VAT notification (details required: VAT number, issuing office, date of issue) Insert details required to evidence verification of business address: 7. Intermediary Declaration Signature of person who has seen the original documentary evidence or visited the client s business premises: Signature Position/Job Title Print name Full name of firm FCA/PRA Registration Number page 6 of 8

7 7. Intermediary Declaration Continued Intermediary Details Name Role Postal Address Address Contact Telephone Number page 7 of 8

8 Instruction to your Bank or Building Society to pay by Direct Debit Please fill in the whole form using a black ball point pen and send it to: Unum Group Credit Control Milton Court Dorking Surrey RH4 3LZ Name(s) of Account Holder(s) Bank/Building Society account number Originator s Identification Number Branch Sort Code FOR UNUM OFFICIAL USE ONLY This is not part of the instruction to your Bank or Building Society Reference Number Name and full postal address of your Bank or Building Society To: The Manager Address Bank/Building Society Instruction to your Bank or Building Society Please pay Unum 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 Unum and, if so, details will be passed electronically to my Bank/Building Society. Signature(s): Postcode :! 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 Unum will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request Unum to collect a payment, confirmation of the amount and date will be given to you at the time of request If an error is made in the payment of your Direct Debit, by Unum 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 Unum 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. page 8 of 8