Statement of Health and Insurability Reinstatement of Cover

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1 Policy Number Name Statement of Health and Insurability Reinstatement of Cover You may be required to complete this statement of health and insurability for a number of reasons including, but not limited to a change of insurability status of the life assured and reinstatement of your policy. Please note that only policies that have been lapsed within 12 months will be considered for reinstatement, subject to underwriting and the full payment of the outstanding premiums. For policies sold in Iceland only

2 Part 1 Introduction It is most important that you read this Part before completing this Statement of Health form. For joint life plans, the lives assured should each complete a separate Statement of Health and Insurability form. If you make a mistake please cross it out, put in the correct word or words and initial next to the correction. Please ensure that you complete all relevant parts of the Statement of Health form correctly. You are entitled to ask for a copy of our standard terms and conditions and a copy of your Statement of Health form at any time. 1 Disclosure of all relevant information Help us to assess your Statement of Health fairly by telling us all the information that may affect our decision to insure you. We ask only relevant questions.you should assume that if we ask a question, it is important.therefore, you must answer all questions accurately and completely to the best of your knowledge. If you do not, Friends Provident International will be legally entitled not to pay a claim and to cancel the policy. IF ANYTHING ABOUT YOUR HEALTH OR CIRCUMSTANCES CHANGES AFTER YOU HAVE COMPLETED THIS STATEMENT OF HEALTH AND BEFORE WE ASSUME RISK FOR THE COVER APPLIED FOR YOU MUST LET FRIENDS PROVIDENT INTERNATIONAL KNOW IMMEDIATELY EITHER VIA YOUR FINANCIAL ADVISER OR US DIRECT AT fp.int@friendsprovident.co.uk. We need to know of any changes which would have resulted in different replies to questions asked either: on or resulting from the Statement of Health form or other questionnaire; or by any doctor or nurse acting on our behalf. Changes would include having, or expecting to have, doctor, hospital or clinic consultations, treatment as an in-patient or out-patient or a blood test for any reason. We also need to know immediately if you change your occupation, country of residence or take up any hazardous sports or pastimes before cover starts. If we are advised of any changes we will confirm in writing whether or not any terms quoted will still apply. 2 Commencement of Cover The Plan will not start, or cover will not re-commence, until we have assessed and accepted your Statement of Health, and we have received a valid credit card authority for payment of premiums. In most instances your payments will be as originally quoted. We may offer you revised terms, but occasionally we may not be able to offer any terms. 3 Medical information We may ask you to contact your doctor if we are waiting for reports, which we have asked for. If we ask you to attend a medical examination, we will need to share the Statement of Health information with any company we authorise to conduct such examinations. They will make the arrangements for the examination to take place. We may need to send your Statement of Health and relevant medical reports to our reassurers for their opinion or agreement of the terms offered. Or, we may need to send them at a later stage for purposes relating to managing the policy. of general reassurance principles and details of any company we use to assess your Statement of Health will be provided by our head office. We have a confidentiality policy in place which fulfills all provisions of the Act on the Protection of Privacy no. 77/2000. We shall hold your medical information securely and access is limited to authorised individuals who need to see it. FRIENDS PROVIDENT INTERNATIONAL WILL ONLY PAY FOR MEDICAL INFORMATION WHICH IT HAS SPECIFICALLY REQUESTED Definitions HIV: Human Immunodeficiency Virus: This is a viral infection caused by the human immunodeficiency virus that generally destroys the immune system. AIDS: Acquired Immune Deficiency Syndrome: This is the most serious stage of HIV infection characterised by symptoms of immune deficiency. XIN34/SOM (ENG) HL /2017 Page 2

3 Part 2 Personal details The Life Assured is the person on whose life the Plan will be written. Please complete in block capitals. 1 Title eg Mr, Mrs, Dr, Miss 2 Last name 3 First name(s) 4 Current residential address (including street name, town and area code if known) 5 Telephone number(s) Work Home 6 address 7 ID number (if applicable) 8 Date of birth 9 Marital status DD MM YY Part 3 Occupation 1 Occupation 2 Nature of employer s business 3 Please give details if you work underground, underwater, at heights over 3 metres, offshore or of any other hazardous aspects of your occupation 4 a) Are you currently absent from work for any reason? Reason and duration If, please give reasons for absence b) Have you had any time off work within the last two years due to illness or injury? You can ignore minor ailments such as colds/flu if together they total less than ten days per year. If, please give reasons for absence 5 Do you intend changing your occupation in the next 6 months. If, please give details of your new occupation and the nature of your new employer s business. Reason Amount of time off XIN34/SOM (ENG) HL /2017 Page 3

4 Part 4 Residential and travel details 1 Do you intend to reside, work or travel outside of Iceland other than for holidays or have you done so within the past 5 years? If yes please provide full details Part 5 Recreation details To qualify for non smoker status rates you must not have used any form of tobacco or nicotine products within the last 12 months. We reserve the right to check the accuracy of your reply if you have indicated on this Statement of Health that you do not use any form of tobacco or nicotine products 1 Have you used any form of tobacco or nicotine products (eg patches, gum etc) in the last 12 months? If, please state what form and how much a day. per day 2 Do you drink alcohol? If, please state number of units per week per week 1 unit = a single measure of spirits or 1 glass of wine or 1 2 pint (250ml) of beer. 3 Have you ever taken non-prescription drugs (eg Ecstasy, Cocaine, Heroin etc)? If yes please provide full details 4 Have you ever suffered from alcohol or drug abuse or been advised by a doctor to reduce or stop your alcohol consumption on medical grounds? If yes please provide full details 5 Do you take part in any hazardous sports or pastimes or do you intend to start? (Mountaineering, motor sports, horseriding, skiing and private flying are examples but you should include any activity that is hazardous). If yes please provide full details Part 6 Insurance history Have you ever applied for life insurance, insurance against critical illness or income protection/disability insurance, and been turned down or asked to pay a higher premium or had other special terms imposed? Company Dates XIN34/SOM (ENG) HL /2017 Page 4

5 Part 7 Family history Your family history will be used to assess the likelihood of you suffering from a similar disease in the future. This may mean that we can only offer cover subject to an extra premium or exclusion. In some circumstances we may be unable to offer cover at all. Failure to provide full and accurate details of a family history that we have asked for may result in non-payment of a claim. To make a decision we need to know the health of your natural parents, brothers and sisters. You must obtain permission from all of these relatives to supply this information. Please tick the box to confirm that permission has been received. If permission has not been received from any of your relatives please tell us why this was not available. If this was because the relative has died or their current whereabouts is unknown, legally you must still disclose this information if it is known to you. If permission has been refused then we regret we are unable to proceed with your application. Before the age of 60, have any of your natural parents, brothers or sisters suffered or died from heart disease, raised cholesterol, stroke, diabetes, cancer, multiple sclerosis, Huntington s disease,tuberculosis, polycystic kidney disease, polyposis of the colon, Parkinson s disease, Alzheimer s disease, or any hereditary disorder? Medical Condition Age at onset of condition If cancer, please state which part of the body was first affected. Part 8 Health questions If the answer to any question is please give full details disclosing all material facts as they can influence the assessment and acceptance of this Statement of Health. If you are in any doubt as to whether any fact is material, you should disclose it. If you do not, Friends Provident International will be legally entitled not to pay a claim and to cancel your policy(ies). If you require more space to write your answers, please use the Additional Information box at the end of this section. You must also at your own initiative provide information about facts you are aware of, or should be aware of, and are of importance, when degree of risk of insurance cover is assessed by Friends Provident International. 1 What is your height? 2 a) What is your weight? b) Have you recently lost or gained any weight? If, please give details. 3 a) Name and address of your doctor Please note we might not contact your doctor. Even if we do, you must still disclose all the material facts when completing this Statement of Health. Telephone Fax b) When did you last attend your doctor DD MM YY 4 Do you currently have or have you ever had any of the following: a) Cancer, leukaemia, Hodgkin s disease, lymphoma, brain or spinal tumour? b) Heart disease (including heart attack, angina, heart defects from birth or heart surgery)? c) Stroke, brain haemorrhage or brain injury? XIN34/SOM (ENG) HL /2017 Page 5

6 Part 8 Health questions (continued) d) Multiple sclerosis, optic or retrobulbar neuritis, Parkinson s disease, paralysis, epilepsy, Alzheimer s disease, dementia or cerebral palsy? e) Any other disorder of the central nervous system not already mentioned? f) Disease or disorder of the arteries (including disease in the legs or of the aorta)? g) Diabetes or sugar in the urine? h) Mental illness that has required hospital treatment or referral to a psychiatrist? i) Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the results of such a test? te: If the result is negative, the fact of having an HIV test will not in itself have any effect on your acceptance terms for insurance. If you answered to any part of question 4, please give details below, including the question number and reference to which it relates, eg 4 a). Number and Reference Please list in this box the disorder(s), date of disorder(s) and duration, treatment, result of investigations, time off work and dates, name and address of doctor attended. 5 In the last 5 years have you had any of the following: a) A mole or freckle that has bled, caused pain or changed appearance or any lump or growth? b) Chest pain, irregular heart beat, raised blood pressure or raised cholesterol? c) Asthma, bronchitis or any other respiratory disorder? d) Numbness, loss of feeling or tingling of the limbs or face, loss of balance or coordination? e) Seizures, fits, fainting or blackouts? f) Any disorder of the eyes or ears including blurred or double vision, or impaired hearing? (You can ignore sight problems corrected by glasses or contact lenses but you should include even temporary visual disturbances for which you were referred to a hospital, clinic, opthalmologist or neurologist) g) Arthritis, back pain, sciatica, neck, knee or wrist pain? h) Any other disorder of the joints, bones or muscles? XIN34/SOM (ENG) HL /2017 Page 6

7 Part 8 Health questions (continued) i) Any disorder of the digestive system, liver, stomach, pancreas or bowel (including ulcers, hepatitis, colitis or Crohn s disease)? j) Any blood disorder or anaemia? k) Thyroid disorder? l) Disorder of the kidney, bladder or the genito-urinary system (including blood or protein in the urine and urinary tract infections)? m) Treatment or a positive test for any disease which was transmitted sexually? n) Depression, anxiety, stress, fatigue or nervous breakdown? o) Medical investigation, scan or test or have you been advised to have such investigations? p) Attendance at a hospital as an inpatient or as an outpatient? q) A surgical operation? If you answered to any part of question 5, please give details below, including the question number and reference to which it relates, eg 5 a). Number and Reference Please list in this box the disorder(s), date of disorder(s) and duration, treatment, result of investigations, time off work and dates, name and address of doctor attended. 6 In the next 12 months: Are you due to have a check-up in connection with any medical conditions or are you waiting for the result of any medical investigations? If you answered to this question, please give details below. Medical condition Date of check up/ medical investigation XIN34/SOM (ENG) HL /2017 Page 7

8 Part 8 Health questions (continued) 7 In the last 12 months: a) Have you had any medical consultation (eg with a doctor, consultant, psychiatrist, hospital, clinic, osteopath etc)? You do not need to give details of occasional consultations with your doctor for just colds, flu, and for consultations for oral contraceptive pills, or smear tests and well man/woman check ups where the results are known and were normal. b) Have you been prescribed drugs, medicines or tablets or had any other form of medical treatment? If you answered to any part of question 7, please give details below, including the question number and reference to which it relates, eg 7 a). Number and Reference Please list in this box the disorder(s), date of disorder(s) and duration, treatment, result of investigations, time off work and dates, name and address of doctor attended. 8 Have you ever undergone any surgical procedure outside Iceland or the European Union or been a recipient of blood products outside Iceland or the European Union? 9 Within the last five years have you been exposed to the risk of HIV infection? te: HIV can be caught through unsafe sex, intravenous drug abuse, blood transfusions undertaken outside Iceland or the European Union or surgery undertaken outside Iceland or the European Union. XIN34/SOM (ENG) HL /2017 Page 8

9 Part 9 Declaration This Declaration must be signed by all persons involved in this Statement of Health. 1 This Statement of Health is my official request to enter into a contract with Friends Provident International together providing the foregoing Plan(s) and benefits. I understand that the contract will be on Friends Provident International s standard terms and conditions which have been explained to me. I have also been provided with all general and special information in accordance with chapter XI of the Act of Insurance Contracts no 30/2004 including a quotation for this Plan/these Plans and have read and understood the Key Facts and Policy Conditions Documents (only applicable where this Statement of Health form is signed in the EEA). I hereby declare that any information and advice about this product given by my Financial Adviser was given only following my approach to the Financial Adviser requesting information and advice on life assurance contracts offered by Friends Provident International. Friends Provident International is regulated by the Financial Conduct Authority in the United Kingdom and is permitted by the FME to promote its products in Iceland in line with Icelandic legislation. I understand that Friends Provident International needs information about my health to establish risk of insurance cover and I also understand that the company may require sight of my medical records to consider a claim. I have been advised in accordance with article 20 of the Act on the Protection of Privacy when rendering personal information in this Statement of Health form. I am residing in Iceland and confirm that to the best of my knowledge and belief I am not subject to any legislation which would make this Plan/these Plans unlawful. I understand that the standard terms and conditions and a copy of this completed Statement of Health are available on request. I understand that where I am applying on the advice of an financial adviser, that financial adviser is acting as my agent and not as an agent of Friends Provident International. 2 I have read my answers to the questions in this Statement of Health and declare that, to the best of my knowledge and belief, all the information I have given is true and that no relevant fact has been withheld. I understand that failure to disclose a relevant fact or the giving of false information will give Friends Provident International the right to cancel from inception any policy issued as a result of this Statement of Health and may invalidate any future claim. I understand that I must at my own initiative provide information about facts I am aware of, or should be aware of, and are of importance, when degree of risk of insurance cover is assessed by Friends Provident International. I accept that if I am required to have a medical examination, the replies to the medical examiner s questions will form part of this Statement of Health. I authorise Friends Provident International to use my family history in order to assess my likelihood of suffering from a similar disease in the future. I understand that any terms offered may have an extra premium or exclusion, or that cover may be declined due to my family history. I understand that I must tell Friends Provident International without delay if my health or circumstances change before Friends Provident International assumes risk for the Plan(s) applied for. 3 I understand that information given to Friends Provident International in connection with this Statement of Health may be used by Friends Provident International in its consideration of any claim in future and may be shared with a third party eg medical examiner, to help in the assessment of a claim. Provisions of the Act on The Protection of Privacy apply to all disclosure of information to third parties. 4 I authorise Friends Provident International to pass medical information to any life insurance company, to any medical examiner, or to any company arranging these examinations on Friends Provident International s behalf. I agree Friends Provident International will use the information I give (as well as information about me relating to any existing policy I may have with Friends Provident International) for administration, underwriting, claims, research and statistical purposes. I agree Friends Provident International may pass information to medical practitioners, underwriters and reinsurers and any agency appointed for these purposes. (These agencies may be located in countries outside the UK that do not have laws to protect your information. of the companies and countries involved in your case will be provided on request. Friends Provident International will remain responsible for making sure that the information is held securely.) I also agree Friends Provident International may pass the information to third parties for the prevention of crime or detection of fraud, enabling assets to be rightfully claimed or where required by law or regulation. All information appearing in this Statement of Health form is confidential, however it can be rendered to third parties for administration, underwriting, claims research and statistical purposes, only if provisions of the Act on the Protection of Privacy are duly fulfilled. 5 I agree to you asking any doctor I have consulted about my physical or mental health to provide medical information so you may assess this Statement of Health. You may gather relevant information from other insurers or reassurers about any other Statement of Healths for life, critical illness, sickness, disability, accident or private medical insurance on my life that I have applied for. I authorise those asked to provide medical information when they see a copy of this consent form, including after my death to support any claim made on the plan proceeds. All information shall be obtained in accordance with the Act on the Protection of Privacy. 6 I would like Friends Provident International to use the information I have supplied to let me know about other products and services in the Aviva group who may use it to advise me of other products and services that may interest me however this is subject to the Act on the Protection of Privacy. Please tick to confirm Signature Date XIN34/SOM (ENG) HL /2017 Page 9

10 Part 10 Payment INSTRUCTIONS: Please complete in BLOCK CAPITALS and hand the form back to either your financial adviser or Friends Provident International. We can only accept payment by credit card. Credit Card Authority We can only accept Mastercard or Visacard If a third party is paying the premiums, please complete a standalone Verification of Identity and Source of Funds form. Until further notice, I authorize Friends Provident International to charge my MASTERCARD/VISACARD account a single unspecified sum followed by GBP YEARLY/MONTHLY (please delete as apropriate) after the policy goes live. Card number Expiry date / Cardholder s name and initials as shown on card MM / ÁÁ Cardholder statement address Signature Date / / DD / MM / ÁÁ I confirm that I have seen the full terms and conditions. The information in this document are in accordance with Friends Provident International understanding of current law and taxation in Iceland, which are subject to change. liability can be accepted for any personal tax consequences of this policy and for the affect of future tax or legislative changes. Policyholders have the protection afforded by the UK Financial Services Compensation Scheme (FSCS). The FSCS makes provision for payments to policyholders if a UK authorized company is unable to meet its financial commitments. Complaints we cannot settle can be referred to the Financial Services Ombudsman. XIN34/SOM (ENG) HL /2017 Page 10

11 Friends Provident International is a business name of Friends Provident International Limited and Aviva Life & Pensions UK Limited for business conducted outside the United Kingdom. Aviva Life & Pensions UK Limited Registered in England Registered office: Aviva, Wellington Row, York, YO90 1WR. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number Salisbury Office: United Kingdom House, Castle Street, Salisbury, Wiltshire SP1 3SH England. Telephone +44(0) Fax +44(0) fp.int@friendsprovident.com Website Friends Provident International is a registered trade mark of the Aviva group. XIN34/SOM (ENG) HL /2017

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