Application for a life assurance plan on the life of another person

Transcription

1 Application for a life assurance plan on the life of another person Before completing this form, please read this information carefully. This form is for use where the applicant wishes to take out a plan on someone else s life. The form can also be used where the plan is to be issued subject to a new trust from the outset and where the plan is to be issued to the trustees of an existing trust. The life or lives to be assured, as applicable, will need to complete a separate application for the plan we refer to this as the linked application form. How to contact us If you have any questions about your application, you can phone us or write to us. We may record or monitor calls to improve our service. Office address: Zurich Assurance Ltd, Tricentre One, New Bridge Square, Swindon SN1 1HN Call us on: We are open from Monday to Friday 8.30am to 6pm. Please fill in the relevant sections of this form in BLOCK CAPITALS and return it to the office address above. How do you use my personal information? We and our selected third parties will only collect and use your personal information (i) where the processing is necessary in connection with providing you with a quotation and/or contract of insurance and/or provision of financial services that you have requested; (ii) to meet our legal or regulatory obligations; or (iii) for our legitimate interests. It is in our legitimate interests to collect your personal information as it provides us with the information that we need to provide our services to you more effectively including providing you with information about our products and services. We will always ensure that we keep the amount of information collected and the extent of any processing to the absolute minimum to meet this legitimate interest. Examples of the purposes for which we will collect and use your personal information are: 1. to provide you with a quotation and/or contract of insurance; 2. to identify you when you contact us; 3. to deal with administration and assess claims; 4. to make and receive payments; 5. to obtain feedback on the service we provide to you; 6. to administer our site and for internal operations including troubleshooting, data analysis, testing, research, statistical and survey purposes; 7. for fraud prevention and detection purposes. We will contact you to obtain consent prior to processing your personal information for any other purpose, including for the purposes of targeted marketing unless we already have consent to do so. Who controls my personal information? This statement tells you how Zurich Assurance Ltd ( Zurich ), as data controller, will deal with your personal information. Where Zurich introduces you to a company outside the group, that company will tell you how your personal information will be used. You can ask for further information about our use of your personal information or complain about its use in the first instance, by contacting our Data Protection Officer at: Zurich Insurance Group, Tri-centre 1, Newbridge Square, Swindon, SN1 1HN or by ing the Data Protection Officer at GBZ.General.Data.Protection@uk.zurich.com. If you have any concerns regarding our processing of your personal information, or are not satisfied with our handling of any request by you in relation to your rights, you also have the right to make a complaint to the Information Commissioner s Office. Their address is: First Contact Team, Information Commissioner s Office, Wycliffe House, Water Lane, Wilmslow, SK9 5AF. NP115761A51 Application for a life assurance plan on the life of another person Page 1 of 8

2 Trusts If you want the plan to be issued in trust from the start date (this means that the trust will come into force when the plan is issued), you need to attach the appropriate completed trust form and the person(s) who are declaring the trust must sign this form. If the trust is already in force and the application is being made by the trustees of the trust, you need to attach the original or a certified copy of the complete trust and all the current trustees must sign this form. If you have not attached a completed trust document we will assume that you do not want the plan to be issued in trust. 1 The life or lives to be assured First life assured Second life assured Declaration date of linked application D D M M Y Y Please ensure that the linked application form, which has been completed and signed by the life or lives to be assured, as applicable, is attached. 2 Applicant(s) Please complete a confirmation of verification of identity certificate for each applicant or where the applicant is a company or a limited liability partnership (LLP) the name of the company or the LLP. or where the applicant is a company or a limited liability partnership (LLP) the name of the company or the LLP. NP115761A51 Application for a life assurance plan on the life of another person Page 2 of 8

3 2 Applicant(s) (continued) or where the applicant is a company or a limited liability partnership (LLP) the name of the company or the LLP. or where the applicant is a company or a limited liability partnership (LLP) the name of the company or the LLP. 3 Insurable interest If you are not sure how to complete this section, please speak to your adviser. Please give details of your insurable interest in the life or lives to be assured. (For example, key individual protection ) NP115761A51 Application for a life assurance plan on the life of another person Page 3 of 8

4 4 Declaration by applicant(s) Your duty to take reasonable care when answering the questions we ask When answering the questions we ask, please take reasonable care to ensure the information you provide is, to the best of your knowledge, complete and correct and answer the questions in this application, and in any additional forms, honestly and accurately. If you and/or the life or lives to be assured do not answer the questions correctly the plan may be cancelled, or its terms may be changed, or a claim may be rejected or not fully paid. Your duty to take reasonable care when answering the questions we ask also affects any option you use to increase your cover that is included in the plan s terms and conditions, and any plan we allow you to have that replaces this one. Please let us know in writing if anything happens between completing this application and the start date of the plan that alters any of the answers you ve given. Please note: your application is subject to acceptance by Zurich Assurance Ltd (Zurich). Completing this application form does not guarantee that we will accept your application and the collection of payments does not mean that we have accepted your application. The terms and conditions for the plan you are applying for are available from us on request. Our address and telephone number are on page 1 of this application form. By completing this application form you are applying to make a legally binding agreement with Zurich. Please read this declaration carefully before signing it. Data protection Disclosures: Where necessary, we will share the personal information you gave us for the purposes of providing you with the goods and services you requested with the types of organisations described below: associated companies including reinsurers, suppliers and service providers; introducers and professional advisers; regulatory and legal bodies; survey and research organisations; credit reference agencies; healthcare professionals, social and welfare organisations; and other insurance companies Or, in order to meet our legal or regulatory requirements, with the types of organisations described below: regulatory and legal bodies; central government or local councils; law enforcement bodies, including investigators; credit reference agencies; and other insurance companies. Where we transfer your personal information to countries that are outside of the UK and the European Union (EU) we will ensure that it is protected and that the transfer is lawful. We will do this by ensuring that the personal information is given adequate safeguards by using standard contractual clauses which have been adopted or approved by the UK and the EU, or other solutions that are in line with the requirements of European data protection laws. A copy of our security measures for personal information transfers can be obtained from our Data Protection Officer at: Zurich Insurance Group, Tri-centre 1, Newbridge Square, Swindon, SN1 1HN, or by ing the Data Protection Officer at GBZ.General.Data.Protection@uk.zurich.com. Rights: You have a number of rights under the data protection laws, namely: to access your data (by way of a subject access request); to have your data rectified if it is inaccurate or incomplete; in certain circumstances, to have your data deleted or removed; in certain circumstances, to restrict the processing of your data; a right of data portability, namely to obtain and reuse your data for your own purposes across different services; to object to direct marketing; not to be subject to automated decision making (including profiling), where it produces a legal effect or a similarly significant effect on you; to claim compensation for damages caused by a breach of the data protection legislation. if we are processing your personal information with your consent, you have the right to withdraw your consent at any time. We will, for the purposes of providing you with a contract of insurance, processing claims, reinsurance and targeted marketing, process your personal information by means of automated decision making and profiling where we have a legitimate interest or you have consented to this. NP115761A51 Application for a life assurance plan on the life of another person Page 4 of 8

5 Declaration by applicant(s) (continued) I/We consent to My/Our personal data being used in the ways set out above and on page 1 of this application. Zurich, its agents, the Zurich Group and any companies they become associated with, using my/our information for setting up, processing and administering my/our plan. Can we keep in touch? With your permission we will share your personal information with other Zurich Group companies so we can let you know about other Zurich products and offers we think will be of interest to you. We won t pass your personal information to any company that isn t part of the Zurich Group. If you are happy with this, please select your preferred option(s). Yes, I would like to receive communications by post (if different from above): County Yes, I would like to receive communications by phone Daytime phone number: Mobile phone number: Yes, I would like to receive communications by address: Yes, I would like to receive communications by text message Mobile phone number (if different from above): Your selection isn t permanent. If you change your mind at any time, you can write to us at: Zurich Insurance Group, Tri-centre 1, Newbridge Square, Swindon, SN1 1HN or by ing GBZ.General.Data.Protection@uk.zurich.com. You can also change your account preferences where you have registered with us. For more information on what we do with the information you give us, please read our Data Protection leaflet Your privacy is important to us, I authorise those asked by Zurich to give such information on production of a copy of this consent. I/We declare that I/We apply for a life assurance plan on the life or lives of the life or lives to be assured, named above, according to the terms of both this application and the linked application referred to above. I/We have answered the questions in this application, and in any additional forms, honestly and accurately and the information I/we have provided in response to the questions is, to the best of my/our knowledge, complete and correct. The information I/we have provided in relation to this application and the answers given, and the declaration made, by the life or lives to be assured in the linked application together form the application for the plan. If the questions haven t been answered correctly, the plan may be cancelled, or its terms may be changed, or a claim may be rejected or not fully paid. Cancelling a plan means that no cover or other benefits will be provided. Where applicable, Zurich can decline the total permanent disability (own occupation) on the life of the life or lives to be assured. Zurich does not need to tell me/us that this benefit has been declined before issuing the plan. The plan schedule will say if this benefit has been included. Where applicable, Zurich can also exclude the guaranteed insurability option, or the special event benefit, as appropriate, from the plan. Zurich does not need to tell me/us that the relevant option has been excluded before issuing the plan. The plan schedule will say if the relevant option has not been included. And where the plan is to be issued in trust from the start date, I/We attach a completed trust form and direct Zurich to issue the plan in trust. And where the application is made by the trustees of an existing trust, I/We attach a copy of the trust and direct Zurich to issue the plan to the trustees of the trust. I am/we are aware that all correspondence and notices will be sent to the first named trustee only, except for cancellation notices which will be sent to each applicant. And where the plan is to be issued subject to the Relevant Life Policy Trust The plan s terms and conditions should be changed so that, if the plan continues after the life to be assured s employment with the principal employer ends, the terminal illness benefit will stop. NP115761A51 Application for a life assurance plan on the life of another person Page 5 of 8

6 Declaration by applicant(s) (continued) Signature(s) of applicant(s): If the applicant is a company or a LLP, the authorised officer(s) should sign on behalf of the company or LLP indicating the position(s) held. Signature(s) Position held I/We consent to the applicant(s) taking out life cover and/or critical illness cover on my life/our lives. Declaration by life or lives to be assured Signature of the first life to be assured: (if 16 years or over) Signature Signature of the second life to be assured: (if 16 years or over) Signature 5 Identification (for IFA use only) I confirm this business has been solicited, sold, signed and completed in the UK and that all persons involved in transacting this business are authorised or exempt persons as defined in the Financial Services and Markets Act 2000 and are permitted to conduct this type of business. Please tick this box to confirm Verification of Identity Please tick as appropriate 1st applicant 2nd applicant The source of funds concession has been applied as the account holder of the Direct Debit instruction is the same as the applicant The source of funds concession cannot be applied. A confirmation of verification of identity certificate has been completed Please let us know if you would like a copy of this in large print or braille, or on audiotape or CD. Zurich Assurance Ltd Registered in England and Wales under company number Registered Office: The Grange, Bishops Cleeve, Cheltenham, GL52 8XX. Telephone: We may record or monitor calls to improve our service. NP115761A51 Application for a life assurance plan on the life of another person Page 6 of 8

7 Confirmation of verification of identity certificate (to be completed by an FCA Regulated or EU Regulated Introducer) Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, and attorneys acting under Power of Attorney and third parties where you have been required to undertake identification). Name of applicant*/trustee*/third party*/attorney* (in full) Mr/Mrs/Miss Other title Date of birth D D M M Y Y Forename Surname Plan number to which this certificate relates: Previous address if moved in last 3 months Telephone number I/We certify that: (a) the information above was obtained by me/us in relation to the customer; (b) the evidence I/we have obtained to verify the identity of the customer: meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG: or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). (tick one only) This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; those whose identity has not been verified by virtue of the application of a permitted exemption under the Money Laundering Regulations; or those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant (Please give reasons) Adviser name Adviser code Financial Services Register number Signature Telephone number Date D D M M Y Y Y Y Name of person completing this certificate Job title * Delete as applicable. Beneficial owners must also be identified if different from the applicants. Note this certificate must be signed by an officer of the Introducer Firm who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records to which this certificate relates. We cannot accept photocopies of completed certificates. Zurich Assurance Ltd Registered in England and Wales under company number Registered Office: The Grange, Bishops Cleeve, Cheltenham, GL52 8XX. Telephone: We may record or monitor calls to improve our service. NP115761A51 Application for a life assurance plan on the life of another person Page 7 of 8

8 Confirmation of verification of identity certificate (to be completed by an FCA Regulated or EU Regulated Introducer) Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors, and attorneys acting under Power of Attorney and third parties where you have been required to undertake identification). Name of applicant*/trustee*/third party*/attorney* (in full) Mr/Mrs/Miss Other title Date of birth Forename Surname Plan number to which this certificate relates: Previous address if moved in last 3 months Telephone number I/We certify that: (a) the information above was obtained by me/us in relation to the customer; (b) the evidence I/we have obtained to verify the identity of the customer: meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG: or exceeds the standard evidence (written details of the further verification evidence taken are attached to this confirmation). (tick one only) This certificate cannot be used to verify the identity of any customer that falls into one of the following categories: those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for such verification; those whose identity has not been verified by virtue of the application of a permitted exemption under the Money Laundering Regulations; or those whose identity has been verified using the Source of funds as evidence. If you have not verified the identity of the applicant (Please give reasons) Adviser name Adviser code Financial Services Register number Signature Telephone number Date Name of person completing this certificate Job title * Delete as applicable. Beneficial owners must also be identified if different from the applicants. Note this certificate must be signed by an officer of the Introducer Firm who is authorised to confirm the accuracy and effectiveness of the firm s customer identification verification records to which this certificate relates. NP115761A51 (04/18) RRD We cannot accept photocopies of completed certificates. Zurich Assurance Ltd Registered in England and Wales under company number Registered Office: The Grange, Bishops Cleeve, Cheltenham, GL52 8XX. Telephone: We may record or monitor calls to improve our service. NP115761A51 Application for a life assurance plan on the life of another person Page 8 of 8