John Garcia. QuoteMe4 TR1 1UF. For office use only

Transcription

1 Data Capture Form The followig pages ca be prited, to allow you to record cliet details i readiess for submittig a applicatio form olie. This paper form must ot be set to the Provider it is oly to be used for recordig iformatio i order to make a olie submissio. Remember that, i may cases, you may obtai a ehaced commissio, or better terms, ad sometimes immediate acceptace, by submittig cases olie usig Weblie electroic submissio services. To submit your busiess electroically, watch out for these buttos o our Web site, oce you have obtaied a illustratio. If you have previously quoted this case, you may apply olie by recallig the quote (usig track ad the fid quote ad eterig the Weblie quote umber, or the cliet s surame or DoB). Look for the eapply lik o a illustratio, or simply requote ad the proceed to a olie applicatio. Alteratively, click the apply butto o our mai meu to obtai a blak applicatio form at ay time the complete the form olie, ad submit it directly to the provider. This form eeds to be prited, completed ad submitted to: Joh Garcia Freepost RSHA-GUUU-HJAR QuoteMe4 186 Treffry Road, Truro TR1 1UF For office use oly Weblie Quote Referece Firm Name Adviser Name Agecy Code Commissio Details Please Sed Correspodece To Weblie Respose Referece Vedor Details Weblie Number FRN Cotact Compay Name Tradig Name Address Phoe Fax Joh Garcia Charlotte James IFA Ltd Quoteme4 Quoteme4 186 Treffry Road Truro Corwall TR1 1UF equiries@quoteme4.co.uk Paret Group (if applicable) Weblie Number FRN Compay Name Subagecy Details (if applicable) Weblie Number FRN Cotact Compay Name Address Phoe This Applicatio Header Page is provided by Weblie for your coveiece, ad does ot form ay part of the isurer s applicatio form. For further details about electroic busiess, please cotact Weblie. Copyright Weblie

2 Pesios Ivestmets Protectio For fiacial advisers oly Persoal Protectio Data capture form Versio umber 09/11 Key poits This Data capture form from AEGON (a brad ame of Scottish Equitable plc) is split ito two sectios. The iformatio i sectio A allows you to get a illustratio from our olie services. Sectio B allows you to collect the further iformatio we eed to progress that olie illustratio to a olie applicatio. You may have to cotact your cliet(s) if we eed additioal uderwritig iformatio. If you do t have access to your cliet(s), the iformatio you eter olie will be automatically saved for 30 days so you ca get i touch with your cliet(s). You ca dowload additioal poit of sale questioaires from our website: You ca also get copies of all our trust literature from our website or by gettig i touch with our customer service cetre. Importat cotact details: Customer Service Cetre: protect_support@aego.co.uk Telephoe: Fax: Uderwritig helplie: Your checklist: I ve give a copy of the Key features documetatio to the cliet I ve give the pull out page Your olie applicatio what happes ext? (page 27) to the cliet Please make sure you sed i the followig additioal iformatio (where ecessary): Completed poit of sale questioaires (if ot already etered ito our olie ew busiess service) Additioal persoal iformatio (if your cliet has chose to write to our Chief Medical Officer separately) Please make sure ay documetatio you sed to us icludes the olie applicatio referece umber, which you ca fid at the top right-had side of the olie services ew busiess screes. Ay additioal iformatio icludig the Geeral practitioer s report coset declaratio should be set to: AEGON Ballam Road Lytham St Aes Lacashire FY8 4JZ For fiacial adviser use oly For the purposes of Fiacial Services Authority reportig: Did you give the applicat(s) advice about choosig to set up this policy? Yes No Adviser referece (Please give your adviser referece as it applies withi your ow orgaisatio. Please do t put your cliet s(s ) ame(s) i this box.) Importat otes for you Olie services service exclusios Please ote that our olie service does t process cases where: the life/lives to be assured are t prepared to submit bak iformatio olie the Direct Debit paymets are t beig made from the life/lives to be assured s persoal UK bak accout the life/lives to be assured have t bee iformed of how their persoal data will be processed the source of fuds cocessio is t beig used for moey lauderig requiremets the life/lives to be assured has/have more tha oe occupatio there s o isurable iterest the life/lives to be assured are t the same as the applicat(s) the life/lives to be assured are residet outside Eglad, Scotlad, Wales or Norther Irelad the life/lives to be assured are residet i the Chael Islads or Isle of Ma Moey lauderig Our olie service requires premiums to be paid from a UK bak accout i the life/lives assured s(s ) idividual or joit ames. Where this is the case, we do t eed ay more idetity verificatio evidece. Page 1 of 32

3 Sectio A The followig iformatio is ecessary for you to obtai a illustratio from AEGON s olie services. Are ay beefits to be i relatio to a mortgage? Yes No First life to be assured () Foreame(s) Secod life to be assured () Foreame(s) Surame Surame Date of birth (dd/mm/yyyy) Date of birth (dd/mm/yyyy) Sex Sex Male Female Male Female Tobacco ad icotie usage (If you tell us that you ve smoked tobacco or used ay other tobacco or icotie products i the last 12 moths, you ll eed to aswer more questios about this i sectio 5.) Do you curretly smoke or have you, i the last 12 moths, smoked or used ay icotie products, such as gum or patches? Tobacco ad icotie usage (If you tell us that you ve smoked tobacco or used ay other tobacco or icotie products i the last 12 moths, you ll eed to aswer more questios about this i sectio 5.) Do you curretly smoke or have you, i the last 12 moths, smoked or used ay icotie products, such as gum or patches? Yes No Yes No If No, we may ask for a simple medical test to cofirm this. Employmet basis Employed full-time Employed part-time over 16 hours Employed part-time uder 16 hours Self-employed Uemployed Occupatio If No, we may ask for a simple medical test to cofirm this. Employmet basis Employed full-time Employed part-time over 16 hours Employed part-time uder 16 hours Self-employed Uemployed Occupatio Idustry Idustry Persoal Protectio Data capture form Page 2 of 32

4 Persoal Protectio meu Please fill i the tables below for the beefits your cliet wats. If your cliet wats more tha oe of the same beefit, please fill i the Extra beefit box at the bottom of each table. All beefits that pay out o death must be o the same beefit basis. Beefit Beefit basis Beefit Beefit Premium Total ad permaet disability Additioal (please tick oe amout term type Not required Ow Ay Activities of beefits box oly) occupatio occupatio daily livig Life protectio Years Guarateed Reewal or optio* Joit life 1st claim to age Idexatio Joit life 2d claim optio Critical illess Years Guarateed Reewal protectio or Reviewable optio * Available if you ve chose a five-year term. Available if you ve chose a five-year term ad reviewable premiums. Joit life 1st claim to age Idexatio optio Life with critical Years Guarateed Reewal illess protectio or Reviewable optio Joit life 1st claim to age Idexatio optio Family icome Years Guarateed Idexatio beefit optio Joit life 1st claim a year Critical illess Years Reviewable Idexatio family icome optio a year beefit Joit life 1st claim Life with critical Years Reviewable Idexatio illess family optio a year icome beefit Joit life 1st claim Gift iter vivos 7 years Guarateed Legislatio optio Gift iter vivos 7 years Guarateed Legislatio optio Extra beefit All critical illess beefits automatically iclude total ad permaet disability. The usual defiitio of total ad permaet disability is ow occupatio. Where this is t available, for example due to the life to be assured s occupatio, we ll offer the best defiitio we ca. If your cliet does t wat this beefit the please choose Not required from the table above. If your cliet wats to iclude the beefit but with the ay occupatio or activities of daily livig defiitios of disability, please tick the relevat box above. If your cliet chooses life protectio or family icome beefit the the attachig total ad permaet disability beefit will be o a reviewable premium basis. For all other beefits, the total ad permaet disability beefit will be o the same premium basis as the mai beefit premium. Please ote: if your cliet wats waiver of premium, please fill i the relevat sectio o page 5. Please make sure you collect full details for each beefit your cliet chooses. Persoal Protectio Data capture form Page 3 of 32

5 Persoal protectio meu (cotiued) Beefit Beefit basis Beefit amout Beefit term Premium type (please tick oe box oly) Total ad permaet disability Not required Ow Ay Activities of occupatio occupatio daily livig Reducig life Years Guarateed protectio Joit life 1st claim Reducig critical Years Guarateed illess protectio Reviewable Joit life 1st claim Reducig life with Years Guarateed critical illess Reviewable protectio Joit life 1st claim Extra beefit All critical illess beefits automatically iclude total ad permaet disability. The usual defiitio of total ad permaet disability is ow occupatio. Where this is t available, for example due to the life to be assured s occupatio, we ll offer the best defiitio we ca. If your cliet does t wat this beefit the please choose Not required from the table above. If your cliet wats to iclude the beefit but with the ay occupatio or activities of daily livig defiitios of disability, please tick the relevat box above. If your cliet chooses reducig life protectio the the attachig total ad permaet disability beefit will be o a reviewable premium basis. For all other beefits, the total ad permaet disability beefit will be o the same premium basis as the mai beefit premium. Please ote: if your cliet wats waiver of premium, please fill i the relevat sectio o page 5. Please make sure you collect full details for each beefit your cliet chooses. Icome protectio Please oly fill i the table below if your cliet wats icome protectio. If your cliet wats a secod icome protectio beefit with a differet deferred period, please fill i the Extra beefit box at the bottom of this table. Beefit Beefit Beefit Premium type Defiitio of icapacity** Deferred Do you If Yes : If Yes : Idexatio basis amout* term Ow Ay suited Activities of period have existig What is the existig How much of this cover optio occupatio occupatio daily work (i weeks) cover beefit amout? do you ited to cacel? Icome Years Guarateed 4 8 Yes protectio or Reviewable No a moth to age 52 a year Icome Years Guarateed 4 8 Yes protectio or Reviewable No a moth to age 52 a year Extra Years Guarateed 4 8 beefit or Reviewable a moth to age 52 Extra Years Guarateed 4 8 beefit or Reviewable a moth to age 52 *The total of all icome protectio beefits payable is limited to 55% of icome. If the life to be assured is t i paid employmet (for example a houseperso or uemployed), the total maximum beefit etitlemet ca t be greater tha 1,250 a moth. The four ad eight week deferred periods are t available if the life to be assured is t i paid employmet (for example a houseperso or uemployed). **If the life to be assured is t i paid employmet (for example a houseperso or uemployed), the activities of daily work defiitio will apply. Persoal Protectio Data capture form Page 4 of 32

6 Icome protectio You oly eed to complete this sectio if you're applyig for icome protectio. Employed yearly eared icome: Self-employed et taxable earigs as show o their Self Assessmet tax form: Employed yearly eared icome: Self-employed et taxable earigs as show o their Self Assessmet tax form: Year 1 Year 2 Year 1 Year 2 Year 3 Year 3 Premium details (to be completed for all beefits) Premium frequecy (by Direct Debit): mothly yearly Premium oly fill i this box if oe of the beefits is premium-drive. Waiver of premium If icome protectio is chose the waiver of premium is automatically icluded ad you do't eed to complete this sectio. If icome protectio is ot chose, the deferred period will start from the date of icapacity ad will be 26 weeks. Please select the defiitio of icapacity required. Beefit required Yes No Please tick oe defiitio of icapacity oly. Beefit required Yes No Please tick oe defiitio of icapacity oly. Ow occupatio Ay suited occupatio Ow occupatio Ay suited occupatio Activities of daily work Activities of daily work Commissio details Please ote that the commissio details etered at illustratio stage will be carried through to ew busiess. Agecy umber (this is your UAN ad comprises of 3 letters ad 3 umbers) Is this applicatio beig provided for the adviser s ow use, for example the itermediary or their appoited represetative, employee, relative, or a relative of a employee of the itermediary? Yes No Iitial plus reewal (Idemity) Lump sum paid the reewal commissio paid after the idemity period. Iitial plus reewal (No-Idemity) Paid i regular istalmets over the iitial period the reewal commissio paid after the iitial period. Level Paid i regular istalmets throughout the life of the policy. Would you like to give up ay commissio? Yes No If yes, what percetage do you wat to give up? % Persoal Protectio Data capture form Page 5 of 32

7 Sectio B The followig iformatio is ecessary i order for you to progress your illustratio to ew busiess. Is there a isurable iterest betwee life 1 ad life 2? (for example spouse/civil parter, shared depedet childre, joit domestic mortgage, livig with parter, joit loa) Please ote: oly aswer this questio if joit cover is beig applied for. Yes No Has the Your olie applicatio what happes ext? sectio from the back of this form bee give to your cliet? Yes No Source of fuds cocessio Moey lauderig guidace icludes a source of fuds cocessio for reduced risk busiess such as AEGON protectio busiess. Where the policyholder(s) ad the premium payer are the same, the source of fuds cocessio allows us to rely o a cheque or Direct Debit istructio from a UK bak accout, i the policyholder(s) idividual or joit ames, to provide evidece of idetity. Is the source of fuds cocessio beig applied for this applicatio? Yes No 1. Persoal details additioal First life to be assured () Title (Mr/Mrs/Miss/Ms/Dr) Previous surame (if chaged i the last five years) Secod life to be assured () Title (Mr/Mrs/Miss/Ms/Dr) Previous surame (if chaged i the last five years) Marital status (tick oe box oly) Sigle Married Civil parter Divorced Separated Widowed Egaged Marital status (tick oe box oly) Sigle Married Civil parter Divorced Separated Widowed Egaged What is your relatioship with the first life to be assured? Spouse/Civil parter Livig with parter Joit loa Shared depedet childre Joit domestic mortgage Total yearly earigs (You do t eed to aswer this questio if you ve already doe so i the Icome protectio sectio.) Total yearly earigs (You do t eed to aswer this questio if you ve already doe so i the Icome protectio sectio.) 2. Cotact details of life/lives to be assured additioal Address Address You oly eed to fill out the followig if your cotact details are differet from those of the first life to be assured. Postcode Postcode Daytime phoe umber Daytime phoe umber Alterative phoe umber Alterative phoe umber Persoal Protectio Data capture form Page 6 of 32

8 3. Mortgage details If ay of the beefits are to be i relatio to a mortgage please fill i the followig. Purpose of loa Name of leder Remortgage of mai residece To buy mai residece To improve mai residece Other (please provide details of the purpose of the loa) Mortgage/loa iterest rate % Address of mortgaged property Same as first life address Type of mortgage (please tick oe box oly) Other New mortgage Existig mortgage Amout of mortgage or loa Term of mortgage or loa years Postcode Do you wat free cover? (for ew mortgages oly) Yes No 4. Icome protectio details You oly eed to complete this sectio if you're applyig for icome protectio. I the evet of icapacity, would you receive icome from your work? I the evet of icapacity, would you receive icome from your work? Yes No Yes No Would this icome from work cotiue after the ed of the deferred period you ve chose? Yes No If Yes, please specify: % of salary received How log would paymet be received? % Would this icome from work cotiue after the ed of the deferred period you ve chose? Yes No If Yes, please specify: % of salary received How log would paymet be received? % 5. Medical details Please aswer the followig questios for all types of beefit. You must ot assume that we'll write to your doctor. Please remember that if you do t aswer the questios fully ad accurately, we may ot pay a claim, ad the whole policy may be cacelled, ot just the beefit uder which you are claimig. (i) How tall are you? m cms ft iches (i) How tall are you? m cms ft iches (ii) How much do you curretly weigh? kgs st lbs (ii) How much do you curretly weigh? kgs st lbs Have you bee registered with a doctor i the UK for the past 12 moths? Yes No Have you bee registered with a doctor i the UK for the past 12 moths? Yes No Persoal Protectio Data capture form Page 7 of 32

9 5. Medical details cotiued Name of curret doctor Surgery ame Address Name of curret doctor Surgery ame Address Phoe umber Postcode Phoe umber Postcode Have you bee registered with your curret doctor for more tha 12 moths? Yes No If No, please give your previous doctor s details below. Name of previous doctor Surgery ame Address Have you bee registered with your curret doctor for more tha 12 moths? Yes No If No, please give your previous doctor s details below. Name of previous doctor Surgery ame Address Phoe umber Postcode Phoe umber Postcode Tobacco ad/or icotie use If you ve told us i sectio A of this form that you ve smoked or used ay type of tobacco or icotie product i the last 12 moths icludig, but ot limited to, cigarettes, cigars, icotie gum/patches or pipe/rolled tobacco, please aswer the followig questios. Has your usage bee limited solely to icotie patches or icotie gum i the last 12 moths? If No, please tell us the type ad average amout you smoke or use a day. For pipe ad rolled tobacco, give the umber of ouces/grams a day. If you have told us that you have ot smoked or used ay type of tobacco or icotie product i the last 12 moths, we may ask for a simple medical test to cofirm this. Type Amout Note 1 ouce = 28 grams Type Amout Note 1 ouce = 28 grams Alcohol cosumptio How may uits of alcohol do you drik o average each week? (Oe pit of beer = 2.5 uits, oe 330ml bottle of beer = 1.5 uits, oe 175ml glass of wie = 2 uits, oe measure of spirits = 1 uit). If you do't drik alcohol please eter 0. uits uits Have you ever bee advised to drik less/o alcohol? If Yes, please give full details of whe ad why this occurred, how may uits you were drikig at the time, the results of ay ivestigatios ad ay treatmet you received. Persoal Protectio Data capture form Page 8 of 32

10 6. Persoal questios Please remember that if you do t aswer the questios fully ad accurately, we may ot pay a claim, ad the whole policy may be cacelled, ot just the beefit uder which you are claimig. Please ote: you oly eed to aswer these questios if you re applyig for either or both of the followig beefits icome protectio or total ad permaet disability beefit. Occupatio Please idicate whether your occupatio ivolves the followig duties ad give details where applicable: Maual work, for example liftig, carryig, workig with machiery or tools If Yes, please give full details. % Average daily % of duties % Average daily % of duties Drivig Average yearly busiess mileage Average yearly busiess mileage Work at heights % Average % of time spet at heights % Average % of time spet at heights m Average height i metres m Average height i metres Please aswer the followig questios for all types of beefit. Travel I the ext 12 moths do you ited to live, work or travel abroad, or have you doe so i the past five years? Please ote: you do't have to tell us about holidays if they total less tha 30 days i ay 12-moth period. If Yes, please fill i the table below: If Yes, please fill i the table overleaf: Future travel/residece (ext 12 moths) Coutry/Coutries Reaso for visit (Choose from Legth of visit (i days) Lived abroad, Movig abroad, Busiess/Work, Holiday/Leisure) Past travel/residece (last five years) You oly eed to aswer the questio below if you re applyig for total ad permaet disability or icome protectio beefits. How may days i total do you expect to sped outside the Uited Kigdom for busiess/work reasos i the ext 12 moths? Persoal Protectio Data capture form Page 9 of 32

11 6. Persoal questios cotiued Travel (cotiued) Future travel/residece (ext 12 moths) Coutry/Coutries Reaso for visit (Choose from Legth of visit (i days) Lived abroad, Movig abroad, Busiess/Work, Holiday/Leisure) Past travel/residece (last five years) You oly eed to aswer the questio below if you re applyig for total ad permaet disability or icome protectio beefits. How may days i total do you expect to sped outside the Uited Kigdom for busiess/work reasos i the ext 12 moths? Leisure Do you ited to take part i ay hazardous activity? Do t iclude oe-off evets such as a parachute jump for charity. If Yes, please tick all that apply. Questioaires for each of these pursuits are available o our website, Fillig i these will help speed up the uderwritig process. If you do t have access to these questioaires, please provide full details of your activities i the Details sectio below. Details: Please give full details, icludig the activity you take part i, how ofte you take part i this activity, details of ay related qualificatios ad ay equipmet you use. Aviatio (other tha as a fare-payig passeger o a licesed airlie) Motor sports Moutaieerig (other tha hill walkig, trekkig, abseilig, artificial wall climbig) Sports divig Other (give details below) Aviatio (other tha as a fare-payig passeger o a licesed airlie) Motor sports Moutaieerig (other tha hill walkig, trekkig, abseilig, artificial wall climbig) Sports divig Other (give details below) Persoal Protectio Data capture form Page 10 of 32

12 6. Persoal questios cotiued Other protectio policies Does the total amout of protectio uder all your existig policies, together with this applicatio ad ay pedig or cocurret applicatios exceed 800,000 for life cover or 500,000 for critical illess or total ad permaet disability (TPD)? Yes No If Yes, please aswer the questios below: Please give details of protectio already i force (please iclude ay existig cover with us): Policy beefit(s)* Amout Reaso for protectio Compay *For example, Life cover/death or earlier critical illess cover (o TPD)/Death or earlier critical illess cover (with TPD)/Critical illess cover (o TPD)/Critical illess cover (with TPD)/TPD Is ay of your existig protectio beig cacelled? Yes No If Yes, please provide details of which protectio is to be cacelled, icludig the ame of the isurace compay ad the policy umber. Please give details of protectio beig applied for (please iclude ay other applicatios to us): Policy beefit(s)* Amout Reaso for protectio Compay *For example, Life cover/death or earlier critical illess cover (o TPD)/Death or earlier critical illess cover (with TPD)/Critical illess cover (o TPD)/Critical illess cover (with TPD)/TPD Is the itetio that all of these applicatios will go i force if accepted? Yes No If No, please give full details. Persoal Protectio Data capture form Page 11 of 32

13 6. Persoal questios cotiued Other protectio policies (cotiued) Does the total amout of protectio uder all your existig policies, together with this applicatio ad ay pedig or cocurret applicatios exceed 800,000 for life cover or 500,000 for critical illess or total ad permaet disability (TPD)? Yes No If Yes, please aswer the questios below: Please give details of protectio already i force (please iclude ay existig cover with us): Policy beefit(s)* Amout Reaso for protectio Compay *For example, Life cover/death or earlier critical illess cover (o TPD)/Death or earlier critical illess cover (with TPD)/Critical illess cover (o TPD)/Critical illess cover (with TPD)/TPD Is ay of your existig protectio beig cacelled? Yes No If Yes, please provide details of which protectio is to be cacelled, icludig the ame of the isurace compay ad the policy umber. Please give details of protectio beig applied for (please iclude ay other applicatios to us): Policy beefit(s)* Amout Reaso for protectio Compay *For example, Life cover/death or earlier critical illess cover (o TPD)/Death or earlier critical illess cover (with TPD)/Critical illess cover (o TPD)/Critical illess cover (with TPD)/TPD Is the itetio that all of these applicatios will go i force if accepted? Yes No If No, please give full details. Persoal Protectio Data capture form Page 12 of 32

14 7. Health questios Please make sure that you aswer all of the questios hoestly ad accurately. If you re i ay doubt about the iformatio we require, you should give full details. I lie with the Associatio of British Isurers policy o geetics ad isurace, you do t eed to tell us about ay geetic test result you ve had if this applicatio, take together with ay other isurace policies you already have, totals 500,000 or less for life isurace, 30,000 or less for icome protectio isurace or 300,000 or less for other types of isurace. Above these limits, you may eed to tell us about certai geetic test results whe applyig for isurace. We ll oly be iterested i geetic test results where the govermet s Geetics ad Isurace Committee (GAIC) has approved them for isurers to use. If you thik this may apply to you, please ask us for details of the curret positio. However, you must tell us if you either have a family history of, are experiecig symptoms of, or are havig treatmet for a medical coditio, icludig ay geetically iherited coditio. If you wish to tell us about a geetic test result, which shows that you have t iherited a geetic disorder, the we ll take this ito accout i settig your premium, provided your cliical geeticist cofirms that the test result idicates a reduced risk of developig the iherited disease. You must ot partially disclose iformatio whe aswerig ay questios or assume that we ll write to your doctor. Whe aswerig the followig health questios you do t eed to tell us about commo colds, iflueza, hay fever, sius trouble, wisdom teeth, vasectomy or shigles. HIV/AIDS Have you ever tested positive for HIV, hepatitis B or C, or are you waitig for the results of such a test? Please ote: if the result is egative, the fact of havig a HIV test will ot, of itself, have ay effect o your acceptace terms for isurace. If you d prefer to write to our Chief Medical Officer at our head office to aswer this questio, please tick the box opposite. If you ve aswered Yes, please tick all that apply. I ve tested positive for HIV I m waitig for a HIV test result I ve tested positive for hepatitis B or C I m waitig for a hepatitis B or C test result I ve tested positive for HIV I m waitig for a HIV test result I ve tested positive for hepatitis B or C I m waitig for a hepatitis B or C test result Withi the last five years have you tested positive or bee treated for ay disease which was trasmitted sexually? If you d prefer to write to our Chief Medical Officer at our head office to aswer this questio, please tick the box opposite. If Yes, please give full details, icludig the duratio of illess, ivestigatios, date of diagosis ad treatmet received. The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 13 of 32

15 7. Health questios cotiued Withi the last five years have you bee exposed to the risk of HIV ifectio? Please ote: HIV ifectio ca be caught through usafe sex, itraveous drug abuse, or blood trasfusios or surgery udertake outside the Europea Uio. If you d prefer to write to our Chief Medical Officer at our head office to aswer this questio, please tick the box opposite. If Yes, please give full details, icludig dates. If you wat to write i cofidece to the Chief Medical Officer, please sed your details o a separate piece of paper direct to our Chief Medical Officer at AEGON, Ballam Road, Lytham St Aes, Lacashire FY8 4JZ, givig your full ame ad date of birth. Please make sure you sig ad date these details. Have you ever take or ijected ay drugs that have t bee prescribed by a doctor? If you wat, you ca fill i ad retur a drugs questioaire. These are available o our website, Please cofirm the ame of the drug. Do you curretly use this drug? If No, whe did you last use this drug (mm/yyyy)? How may times a moth do you use/did you use this drug? Do you ow have, or have you ever had, ay of the followig: Agia, heart attack, stroke, trasiet ischaemic attack (TIA), brai haemorrhage or brai ijury? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? How may times have you suffered from this coditio/ how may attacks have you had? Whe did you last suffer from this coditio/whe was your last attack (mm/yyyy)? Have you made a full recovery? If No, please give full details. The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 14 of 32

16 7. Health questios cotiued Do you ow have, or have you ever had, ay of the followig: Chest pai, palpitatios, heart murmur or ay disease or abormality of your heart, pulse, veis or arteries? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Have you had ay medical ivestigatios or hospital admissios i relatio to this coditio? Please ote: ivestigatios iclude GP cosultatios, blood tests, ECG etc. Yes No Awaited Yes No Awaited Please give full details, icludig the results of ay ivestigatios ad details of ay uderlyig cause idetified. How may times have you suffered from this coditio? Have you had surgery i relatio to this coditio? If Yes, whe was the surgery (mm/yyyy)? Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Whe were your last symptoms (mm/yyyy)? Cacer, tumour, Hodgki s disease, lymphoma or leukaemia? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Whe did you last receive treatmet for this coditio (mm/yyyy)? Please ote: treatmet icludes surgery/chemotherapy/ radiotherapy/medicatio. How may times have you suffered from this coditio? Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 15 of 32

17 7. Health questios cotiued Do you ow have, or have you ever had, ay of the followig: Diabetes or sugar i the urie? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Ay coditio of the ervous system such as epilepsy, fits or blackouts, multiple sclerosis, Parkiso s disease, Alzheimer's disease, demetia, cerebral palsy or paralysis? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? The followig questios are for epilepsy, fits or blackouts oly. O average, how may attacks do you have i a year? Whe was your last attack (mm/yyyy)? Metal illess that has required referral to a hospital, commuity metal health team or psychiatrist? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? How may times have you suffered from this coditio? Whe did you last suffer from this coditio (mm/yyyy)? Whe did you last have ay treatmet for this coditio (mm/yyyy)? Please ote: treatmet icludes medicatio, cousellig etc. How may days have you take off work i the last five years as a result of this coditio? Have you ever attempted suicide? If Yes, how may times ad whe was the last time? The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 16 of 32

18 7. Health questios cotiued Do you ow have, or have you ever had, ay of the followig: Ay disorder of the eyes (icludig blurred or double visio) or the ears (icludig impaired hearig)? You ca igore sight problems corrected by glasses or cotact leses, or hearig problems corrected by hearig aids. Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? What caused this coditio (eg cogeital/from birth, accidet/ijury, disease/illess)? Have you had surgery i relatio to this coditio? Do you have ay residual visio/hearig impairmet as a result of this coditio? Which eye or ear is/was affected? How may times have you suffered from this coditio? Whe were your last symptoms (mm/yyyy)? Other tha previously stated, i the last five years have you had, bee treated for or bee advised to have follow-up for ay of the followig: Raised blood pressure? Whe were you first oted to have raised blood pressure (mm/yyyy)? How may differet types of medicatio do you take for your raised blood pressure? If you do t take ay medicatio, please give full details of your raised blood pressure coditio icludig the results of ay ivestigatios performed, whether your blood pressure retured to ormal without treatmet ad details of ay follow-up required. Have you ever ot take or stopped your medicatio without your doctor s approval? Has your medicatio chaged, the dosage icreased or have you bee referred for further ivestigatio, other tha regular follow-up checks, i the last six moths? The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 17 of 32

19 7. Health questios cotiued Other tha previously stated, i the last five years have you had, bee treated for or bee advised to have follow-up for ay of the followig: Raised blood pressure? (cotiued) Whe did you last have your blood pressure checked by a medical practitioer (mm/yyyy)? Do you kow what your blood pressure was whe it was last checked by a medical practitioer? If Yes, what was it? Systolic Diastolic Raised cholesterol? Please give full details. A lump, growth or cyst of ay kid, or ay mole or freckle that has bled, become paiful, chaged colour or icreased i size? Please give the precise medical diagosis. Please cofirm the exact site of the cyst, lump, lesio or growth. Whe were you diagosed with this coditio (mm/yyyy)? Has the cyst, lump, lesio or growth bee completely removed? Has the cyst, lump, lesio or growth bee cofirmed as beig (o-cacerous)? Are you curretly receivig follow-up checks? If Yes, please give the date of the ext follow-up (mm/yyyy). Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Numbess, tiglig, tremor, temporary loss of muscle power, or loss of balace or co-ordiatio? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Please give ay uderlyig cause, if applicable. How may times have you suffered from this coditio? Have you fully recovered with o ogoig symptoms, treatmet or follow-up required? If No, please give full details. Persoal Protectio Data capture form Page 18 of 32

20 7. Health questios cotiued Other tha previously stated, i the last five years have you had, bee treated for or bee advised to have follow-up for ay of the followig: Asthma, brochitis or ay other chest or lug disorder? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? How may times have you suffered from this coditio? Whe did you last experiece symptoms or take treatmet for this coditio (mm/yyyy)? Have you bee admitted to hospital i the last two years? How may courses of steroid tablets (for example Predisoloe) have you take i the last two years? How may days have you take off work i the last 12 moths as a result of this coditio? Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Axiety, depressio, stress, fatigue or ay form of ervous or metal disorder, icludig work-related stress? Please give the precise medical diagosis. Whe were you first diagosed with this coditio (mm/yyyy)? Are you curretly sufferig from this coditio? Are you curretly receivig medicatio ad/or treatmet or cousellig? Have you ever received ipatiet treatmet due to this coditio? Have you ever received care by a psychiatrist or other medical professioal other tha your GP/practice urse, or are you waitig to do so? How may times have you suffered from this coditio? Whe did you last suffer from this coditio or receive treatmet/ cousellig (mm/yyyy)? How may days have you take off work i the last five years as a result of this coditio? Have you ever attempted suicide? If Yes, how may suicide attempts have you made ad whe was your last attempt? The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 19 of 32

21 7. Health questios cotiued Other tha previously stated, i the last five years have you had, bee treated for or bee advised to have follow-up for ay of the followig: Aaemia or ay blood or thyroid disorder? Please give the precise medical diagosis. Please give ay uderlyig cause, if applicable. Whe were you diagosed with this coditio (mm/yyyy)? Do you take prescribed medicatio ad/or treatmet for this coditio? Have you bee advised by a medical practitioer that your blood levels have retured to ormal/that your coditio is satisfactorily cotrolled? Ay disorder of the digestive system, liver, stomach, pacreas or bowel, icludig gastric or duodeal ulcer, hepatitis, colitis or Croh s disease? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Have you had ay medical ivestigatios i relatio to this coditio? Yes No Awaited Yes No Awaited Please give ay uderlyig cause, if applicable. Have you had surgery i relatio to this coditio? Yes No Awaited Yes No Awaited How may times have you suffered from this coditio? Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Whe were your last symptoms (mm/yyyy)? How may days have you take off work i the last 12 moths as a result of this coditio? The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 20 of 32

22 7. Health questios cotiued Other tha previously stated, i the last five years have you had, bee treated for or bee advised to have follow-up for ay of the followig: Ay disorder of the kidey, bladder, prostate or geito-uriary system, icludig blood or protei i the urie? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Have you had ay medical ivestigatios i relatio to this coditio? Yes No Awaited Yes No Awaited Please give ay uderlyig cause, if applicable. Have you had surgery i relatio to this coditio? Yes No Awaited Yes No Awaited How may times have you suffered from this coditio? Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Whe were your last symptoms (mm/yyyy)? How may days have you take off work i the last 12 moths as a result of this coditio? Ay arthritis, gout, joit or muscle problems, icludig the kee(s), shoulder(s), eck, back or spie? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Are you curretly uable to work or carry out your usual daily activities? Please give ay uderlyig cause, if applicable. Have you had surgery i relatio to this coditio? Yes No Awaited Yes No Awaited If Yes/Awaited, please give full details of the surgery icludig joit(s) ivolved ad date. How may times have you suffered from this coditio? Which joit(s)/part(s) of the body does this coditio affect? The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 21 of 32

23 7. Health questios cotiued Other tha previously stated, i the last five years have you had, bee treated for or bee advised to have follow-up for ay of the followig: Ay arthritis, gout, joit or muscle problems, icludig the kee(s), shoulder(s), eck, back or spie? (cotiued) Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Whe were your last symptoms (mm/yyyy)? How may days have you take off work i the last five years as a result of this coditio? The followig questios are for arthritis or gout oly. O average how may attacks do you have each year? Which of the followig best describes your coditio? (Please tick oe optio oly) Pai/stiffess (maily early morig/late eveig), o limitatio of movemet i affected joits, o deformity of joits, able to walk uaided. Pai/stiffess is t limited to early morig/late eveig, some limitatio of movemet i affected joits, some assistive devices eeded, eg a device to ope a screw bottle top, able to walk uaided. No complete freedom from stiffess/pai, serious restrictio of movemet i affected joits, marked deformity of joits, eed help with day-to-day activities, regularly use walkig aids. (This questio is for both males ad females) Ay breast disorders, for example lumps, cysts, ipple discharge or iverted ipple, or a abormal mammogram? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Has this bee fully ivestigated? If Yes, please give full details. Have you bee diagosed with a cyst/lump? For cyst/lump has the cyst, lump, lesio or growth bee completely removed? For cyst/lump has the cyst, lump, lesio or growth bee cofirmed as beig (o-cacerous)? Are you curretly receivig follow-up checks? If Yes, please give the date of the ext follow-up (mm/yyyy). The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 22 of 32

24 7. Health questios cotiued Other tha previously stated, i the last five years have you had, bee treated for or bee advised to have follow-up for ay of the followig: (This questio is for females oly) A abormal cervical smear or other gyaecological disorder from which you have t fully recovered ad/or bee discharged from follow-up? Please give the precise medical diagosis. Whe did you first suffer from this coditio (mm/yyyy)? Whe were your last symptoms (mm/yyyy)? What ivestigatios have you had i relatio to this coditio? Please ote: ivestigatios iclude GP cosultatios, blood tests, scas etc. What treatmet have you had i relatio to this coditio? Please ote: treatmet icludes surgery, medicatio etc. Has the coditio bee cofirmed as beig (o-cacerous)? Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios ad bee discharged from follow-up? If No, please give full details. The followig questios are for borderlie/abormal smear tests oly. Please tell us the CIN (Cervical Itraepithelial Neoplasia) gradig if kow. Have all of your subsequet smear tests bee ormal? The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 23 of 32

25 7. Health questios cotiued To the best of your kowledge, have ay of your parets, brothers or sisters, before the age of 65, died or suffered from ay of the diseases/disorders idicated below? If Yes, please fill i the table below: Disease/Disorder Relatioship Age at diagosis Relatioship Age at diagosis Relatioship Age at diagosis Heart disease Stroke Diabetes Cacer or tumour (Please give site/type) Alzheimer s disease Parkiso s disease Polycystic kidey disease Polyposis of the colo Motor euroe disease Multiple sclerosis Hutigto s disease Muscular dystrophy Hypertrophic cardiomyopathy (HOCM) Ay other hereditary disorder Disease/Disorder Relatioship Age at diagosis Relatioship Age at diagosis Relatioship Age at diagosis Heart disease Stroke Diabetes Cacer or tumour (Please give site/type) Alzheimer s disease Parkiso s disease Polycystic kidey disease Polyposis of the colo Motor euroe disease Multiple sclerosis Hutigto s disease Muscular dystrophy Hypertrophic cardiomyopathy (HOCM) Ay other hereditary disorder The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 24 of 32

26 7. Health questios cotiued Are you awaitig the results of ay ivestigatios or are you aware of ay symptoms or complaits that you have t cosulted a doctor or received treatmet for? Please tell us the symptoms or complait you have suffered from. Please give us full details. Do you have ay other iformatio to give us about ay medical ivestigatio, test or cosultatio, advice, cousellig, operatio, medicatio or treatmet that you've had or bee advised to have or are curretly havig, but have't already told us about? Please give the precise medical diagosis. Whe were you diagosed with this coditio (mm/yyyy)? Have you had ay medical ivestigatios or hospital admissios i relatio to this coditio? Please ote: ivestigatios iclude GP cosultatios, blood tests, ECG etc. Please give full details, icludig the results of ay ivestigatios ad details of ay uderlyig cause idetified. How may times have you suffered from this coditio? Have you had surgery i relatio to this coditio? If Yes, whe was the surgery (mm/yyyy)? Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Whe were your last symptoms (mm/yyyy)? You oly eed to aswer this questio if you re applyig for critical illess, total ad permaet disability or icome protectio beefits. Please ote: you do t have to give details relatig to aythig you ve already told us about. Durig the last five years have you bee off work or uable to carry out your ormal duties due to sickess, accidet or ijury for more tha five days at ay oe time, other tha previously disclosed? Please give the reaso for the time off, dates, duratio, whether ay medical advice was sought ad whether ay treatmet was give. Have you fully recovered with o ogoig symptoms, treatmet, residual problems or complicatios? If No, please give full details. Persoal Protectio Data capture form Page 25 of 32

27 8. Cliet coset Do you wat to see ay medical report before it is supplied to AEGON? Yes No Yes No We may share your persoal iformatio with compaies i the AEGON UK plc group. The AEGON UK plc group may tell you about our ew products or services from time to time. Where AEGON UK plc group is used, this meas Scottish Equitable plc ad ay associated compaies. Do you wat to get such iformatio? Yes No Yes No 9. Trust details Will you be writig this policy uder trust? Yes No We ll sed you a draft of our flexible trust deed together with the policy schedule. Please do't submit a trust form before receivig the Policy schedule. Note: Busiess trusts ca t be used with this applicatio. 10. Policy start date O risk immediately o acceptace at stadard terms To be advised (If the case has bee accepted, you ca iput a start date later through the Recall facility) A future start date (dd/mm/yyyy) (Acceptace terms are valid for a maximum of 30 days) The full rage of poit of sale questioaires ca be dowloaded from Persoal Protectio Data capture form Page 26 of 32

28 The followig iformatio should be give to your cliet. Your olie applicatio what happes ext? You ve chose to apply olie for a protectio policy with AEGON (a brad ame of Scottish Equitable plc). This documet will tell you what happes ext ad cotais some importat otes for you. What happes ext? Your adviser will ow submit your applicatio o your behalf usig our olie service. As soo as we receive your electroic applicatio, a Cofirmatio pack will be set to the address of the first life to be assured, this will cotai details for both lives to be assured if this is a joit applicatio. The Cofirmatio pack will iclude: 1. a Applicatio record (this will show the iformatio that has bee submitted electroically o your behalf) 2. a Declaratio 3. a Cofirmatio form 4. a prepaid reply evelope Your Applicatio record Please read this documet carefully to make sure all the iformatio is correct. If there are ay mistakes or missig iformatio, you should fill i sectio 1 of the Cofirmatio form ad retur it to us immediately. Your Declaratio Please read this documet carefully as it cotais importat iformatio ad forms part of the basis of a cotract betwee you ad AEGON. Your Cofirmatio form Please read this documet carefully as it forms part of the basis of a cotract betwee you ad AEGON. Please remember, both life 1 ad life 2 (where appropriate) should sig ad date the Cofirmatio form ad retur it to us i the eclosed prepaid retur evelope. PLEASE MAKE SURE YOUR ADVISER HAS GIVEN YOU A COPY OF THE KEY FEATURES DOCUMENTATION FOR THIS PRODUCT. IF WE DON T RECEIVE A SIGNED AND DATED CONFIRMATION FORM WITHIN 60 DAYS OF THE DATE ON YOUR CONFIRMATION PACK COVERING LETTER THEN: YOU WON T BE COVERED FOR THE PROTECTION BENEFITS YOU VE CHOSEN IF YOUR POLICY HAS ALREADY STARTED THEN IT WILL BE CANCELLED Importat otes It s importat that you read ad uderstad the followig iformatio: The questios we ve asked cover the facts that we thik are importat to our assessmet of your applicatio. The iformatio iput electroically by your adviser, together with ay other iformatio collected, will form part of the applicatio that s submitted to us o your behalf. AEGON is the data cotroller of the persoal data that I, or someoe o my behalf, give you. We ll use the iformatio you ve provided for purposes i coectio with the cotract (ad related services) which you ve applied for. This icludes the processes of uderwritig, admiistratio, claims maagemet ad customer complait hadlig. Whe aswerig a questio you re persoally resposible for makig sure you ve give complete ad accurate iformatio. You should t make ay persoal assessmet about whether the iformatio is relevat or ot, or assume that we ll write to your doctor for medical iformatio. If you re i ay doubt about the iformatio required, you should give full details. You must tell us i writig if there s ay chage i your circumstaces (for example fiacial iterest, health, lifestyle, occupatio or employmet status ad/or recreatioal activities) betwee the date you aswered the applicatio questios ad the start date of your policy. If there s ay chage i your circumstaces at all, you should tell us. If you do t give full ad accurate iformatio, as detailed above, all the protectio provided by the policy could be lost or cacelled i the evet of a claim, ot just the beefit affected or the beefit that's beig claimed uder. Please be aware that if you re applyig for isurace with other compaies at the same time, by sigig the Cofirmatio form you re cosetig to us sedig copies of medical reports to these other compaies if they ask for them. However, if they ask us for ay highly sesitive iformatio, icludig HIV or geetic test results, we ll ask your specific permissio before we sed it. The Declaratio, Cofirmatio form ad Direct Debit together with the data iput electroically, will form the applicatio ad therefore the basis of the cotract. Persoal Protectio Data capture form Page 27 of 32