The Life Protector Plan

Transcription

1 The Life Protector Plan Application for Assurance Life Protector (an Annually Renewable Life assurance) pays a lump sum in the event of death by natural or accidental cause. Policy carries a five year pre existing exclusion as standard. Accidental Death or Dismemberment pays an additional lump sum benefit in event of death or dismemberment (loss of limbs and/or eyesight) by accidental cause. How to complete this application form Please complete in black ink Please print clearly One letter per block Part A. Personal Details Title Initials Surname First Name (s) as per ID /Passport Passport Number /ID number Country of issue Sex Date of birth m f y y y y m m d d Nationality Place of birth Country of residence Marital Status Full Residential Address Telephone (H) Telephone (W) Full Postal Address address (correspondence and policy documents will be issued to this address) Occupation and Duties Annual Salary (US$/GB / ) 1

2 Part B. Details of cover required PLEASE SELECT THE CORRECT COVER REQUIRED AND COMPLETE THE DETAILS IN FULL. Life cover Currency USD/ GBP/EURO Amount of cover required: Premium Quoted Premium frequency Annually Semi Annually Monthly Reason for cover? Family Protection Loan cover Keyman / business insurance other please give details below Accidental Death and Dismemberment Do you require AD&D? yes no Premium Quoted TOTAL COMBINED PREMIUM Existing / declined insurance Have you effected or proposed for cover on your life within the last two years, or are you making a concurrent application to any other Insurer? yes no If yes, please give details of cover amount and insurers: Has any proposal for life, sickness, accident, health or disability insurance on your life, or request for reinstatement thereof, ever been declined, postponed, accepted on special terms or modified in any way? yes no If yes, please give details of insurers: Anticipated Travel Patterns Please give details of any travel abroad you are likely to undertake other than for holidays in the EU, Western Europe or North America Hazardous Pursuits Do you participate in hazardous activities? yes no If yes please give details of any flying (other than as a passenger) or hazardous sports e.g diving, climbing, racing. Part C. Beneficiary(ies) Details In the event of the death of the life(lives) insured on whose death benefits become payable, as specified in the policy schedule, I hereby appoint the beneficiary/ies named below to receive the benefits, in the percentages stated below; share of benefits add up to 100%) If not completed, the beneficiary will be the estate of the applicant. In order to change the elected beneficiary, approval of such beneficiary will be required. Primary Beneficiaries Name (first, middle initial, last) Relationship Passport/ID number % If Beneficiary is under age 18, a Guardian MUST be appointed to collect the death proceed on the minor s behalf. 2

3 Part D. Health Declaration Please complete the answers below in full. Incomplete forms may delay the application. Your Height (cm s/feet) Your weight (lbs/kgs) Have you smoked any form of tobacco in the last twelve months Do you consume alcoholic beverages? yes no Type & frequency yes no Type, frequency & Quantity Please provide Name, Address, and Telephone number of your usual Doctor: Name: Address: Contact Telephone Number: If you have changed your Doctor in the last five years, please also provide Name, Address, and Telephone number of the previous Doctor: Name: Address: Contact Telephone Number: Have you consulted him/her or any other Doctor in the last five years? If yes, please give details of complaint and date. Please tick the appropriate boxes below to indicate whether you have suffered from any of the conditions listed If the answer is yes to any of the below you will be required to complete the appropriate section of the supplementary Medical conditions Questionnaire 1. Anxiety and/or depression? yes no 2. Arthritis? yes no 3. Asthma and/or Bronchitis yes no 4. Epilepsy? yes no 5. High Blood Pressure? yes no 6. Any Stomach/Bowel Complaint? yes no 7. Diabetes? yes no If the answer is yes to any of the following 7 questions please detail in the space allocated below. 1. Any chest or lung disorder other than Asthma or Bronchitis? yes no 2. Heart Disease, rheumatic fever or chest pain? yes no 3. Any disorder of the bladder, kidney or prostate? yes no 4. Any nervous or mental disorder other than anxiety or depression? yes no 5. Any other ailment or injury needing medical attention? yes no 6. Have you had any operations, x rays or special investigations? yes no If you prefer, answers to question 7 may be answered separately and sent in a sealed envelope 7. Have you ever been tested positive for HIV/AIDS or Hepatitis B or C, or have you been treated for any other sexually transmitted diseases or are you awaiting results of such a test? yes no 3

4 Question No. Diagnosis of illness and the name and address of the treating physician. Date of diagnosis Full details of treatment and tests received, and test results (attach medical reports where possible) Dates of treatment and / or tests Your present state of health with regard to the ailment. If treatment is still being received, please give full details. Please give medical histories for your close relatives including details of any heart disease, stroke, raised blood pressure, diabetes, cancer or kidney disease, multiple sclerosis, including age at onset or disease if known. Living: Deceased: Present Age: Present State of Health Age at Death Cause of Death Duration of Illness Father Mother Brother Brother Sister Sister Part E. Declaration Declaration (Please read carefully before signing) I, the Life to be assured, and (if different) the Grantee, declare that to the best of my knowledge and belief all the statements made in this proposal are true and complete. I undertake to inform the Underwriters of any changes to these statements which occur before the contract completes and I understand that failure to do so may affect the validity of the contract. Failure to disclose any material facts known to me may invalidate the contract. (A material fact is one that is likely to influence the Underwriters' acceptance or assessment of your proposal. You should consult your insurance adviser if in any doubt as to what may be a material fact.) I, the Life to be assured consent to the Underwriters seeking medical information from any doctor who has attended me concerning anything which affects my physical or mental health or seeking information from any Insurer to whom a proposal has been made for assurance on my life and I, authorise the giving of such information. I do / no not * wish to see the report before it is sent to the Underwriters. Signature of Life to be assured Date Full Name and address of Financial Advisor Financial Advisors Agency Number 4

5 Part F. Medical Conditions Questionnaire Complete the appropriate section only after filing in the Proposal Form If you suffer, or have suffered at any time from any of the following conditions, please complete the corresponding section(s) of this Questionnaire: ANXIETY/DEPRESSION (Section 1) ARTHRITIS (Section 2) ASTHMA/BRONCHITIS (Section 3) EPILEPSY (Section 4) HIGH BLOOD PRESSURE (Section 5) STOMACH OR BOWEL COMPLAINTS (Section 6) DIABETES (Section 7) The appropriate section(s) should be completed at the same time as the proposal. The questions should be answered as fully as possible to avoid delay in acceptance. Answers may be continued on a further sheet of paper if there is not enough room on the form. After answering the questions, please complete the declaration below. DECLARATION I declare that the answers given in this questionnaire are to the best of my knowledge true and that I have not withheld any information that may influence the acceptance of my proposal. I agree that this questionnaire will form part of my proposal for assurance and that failure to disclose any material facts known to me may invalidate the contract. (A material fact is one that is likely to influence the Underwriters' acceptance or assessment of your proposal. You should consult your insurance advisers if in any doubt as to what may be material fact.) Signature of Life to be Assured Date(s) 5

6 PLEASE ANSWER ONLY THOSE SECTIONS THAT APPLY TO YOU 1. ANXIETY/DEPRESSION On what date did you first consult a Doctor about this? How many attacks have you had since then? Have you ever lost time off work with this complaint? When and for how long? What tablets have you been prescribed? Are you taking any now? What sort? When is your next appointment? Have you been treated as an out patient at a hospital? When and where? Have you been treated as an in patient? When and for how long? At what hospital? What treatment did you receive there? Was your anxiety/depression triggered by any particular factor? Please say what this was? Have you ever attempted suicide? Please give brief details and date? 2. ARTHRITIS What Form of arthritis do you have? (for example Rheumatoid Arthritis, Osteoarthritis.) Osteoarthritis: Which joints are affected? Are your movements restricted? How much? Have you had or been advised to have an operation? If so, please give details and dates. Rheumatoid Arthritis When was this first diagnosed? What is the extent of your disability? What drugs have been prescribed since diagnosis, and which if any are you still taking? Do you have regular checks? By whom? 6

7 3. ASTHMA/BRONCHITIS When was this first diagnosed? How many attacks have you had? What drugs have been prescribed since diagnosis? Which if any are you still taking? Do you have regular check ups? How often? By whom? Have you ever been admitted to hospital? When? Was it an emergency admission? Have you ever had time off work with asthma and/or bronchitis? Do you smoke? What and how much? 4. EPILEPSY When was this first diagnosed? Did you have a scan or any other tests? Please give details of the results of these, if you were told them. Does anything seem to bring on your attacks? What sort of attacks are they? (i.e. "absences" (petit mal), or fits (grand mal). How often do your attacks happen? When was the last one? What drugs have you been prescribed, and which are you taking now? Do you have regular checks? Where and with whom? 5. HIGH BLOOD PRESSURE Do you have regular checks? Where and with whom? Please give the reading at that time if you know it? Has any investigations been carried out at any time to discover a cause for this condition? Was there to your knowledge any result of these investigations, and what was it? What drugs have you been prescribed? What drugs are you taking now? What is the dosage? Are you under treatment for any other condition? Has your urine been tested? Were you told it was normal? 7

8 Do you have regular checks? Where and with whom? Have you been told that your blood pressure is now normal? How long ago was this? Do you know what the reading was then? What was it? Do you know the level of any readings since then? What were they? Do you smoke? What and how much? 6. STOMACH OR BOWEL COMPLAINTS What were your symptoms? When did they occur? What treatment was prescribed? Did it include any drugs? What were they? Are you still taking them or following any course of treatment? Have you had a barium meal or any other investigation? When was this performed? Were you told of the result? What was it? Have you had an operation? When was it performed, and what kind was it? Have you had any problems since then? Are you still being followed up? Where and by whom? Or have check ups ceased? When? 7. DIABETES When was this first diagnosed? Please give the name and address of the doctor or clinic treating you. Do you follow a strict diet? Are you taking any drugs by mouth? Which drug and what is the dosage? Are you using insulin? What type and how many units do you use per day? Has your intake of insulin or drugs by mouth varied during the last two years? If so, please give details 8

9 Do you check your own urine regularly? If so, how often does it contain sugar? (never/rarely/occasionally/often?) Since treatment began, have you had a diabetic or insulin coma? Please give dates and any details you know. Do you, or have you ever suffered from any disease of the heart, kidneys, eyes or circulatory or nervous systems? Please give details. Please use this page for any answers too long for the space allowed. 9

10 Part F. Payment Instructions You may use any one of these methods to pay the premiums for your Life Protector Plan. 1. CHEQUE I/We attach a cheque made payable to Global Benefits Europe B.V for $ / / * 2. CREDIT CARD/ DEBIT CARD CREDIT CARD AUTHORITY I authorise Global Benefits Europe to collect payment from my please tick appropriate box: MASTERCARD VISA DEBIT OTHER account with the amounts specified as follows: please tick appropriate box: Premium Currency EURO US DOLLARS STERLING The amount in figures The amount in words Frequency Annually Semi Annually Monthly (please tick appropriate box) Mr/Mrs/Miss/Other Cardholders name and initials: Address: Card Number cvv Expiry Date: Issue Date: Issuing Bank Country Of Issue Signature Date 3. STANDING ORDER Please complete the standing order form and submit to your bank. 10

11 4. TELEGRAPHIC TRANSFER For TT's please use the accounts below Please pay into the currency account that your policy is in. Account Name Global Benefits Group Inc. HSBC Bank 20 Eastcheap London EC3M 1ED GBP Account no: Sort code: IBAN: GB07MIDL US$ Account no: Sort code: IBAN: GB64MIDL EURO Account no: Sort code: IBAN: GB46MIDL