Application for Health Plan Protector

Transcription

1 Contact us Tel: , PO Box 3888, Rivonia, 2128, Application for Health Plan Protector How to complete this application form Please complete in black ink Please print clearly One letter per block 1. Plan details 1. Discovery Health Plan details Discovery Health member number Are you also applying for a Discovery Health Plan? Yes No Which Discovery Health Plan are you on? Comprehensive Core Saver InHouse scheme KeyCare Plus KeyCare Core Priority Which LA Health Plan are you on? LA Comprehensive LA Active LA Core LA ocus LA KeyPlus Are you a member of Vitality or KeyClub? Vitality KeyClub (You must be a member of Vitality or KeyClub to purchase the Health Plan Protector) Yes No Yes No If no, would you like to join Vitality or KeyClub? Vitality KeyClub Yes No Yes No 2. Client details 1. Principal life/owner Title Initials Surname irst name(s) (as per identity document) Previous/maiden name ID or passport number Sex Date of birth (please include copy of passport) Nationality of passport Telephone (H) ax (W) Cellphone address Postal address Residential address Work address Page 1 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/ AHPPE 02/10

2 2. Client details (continued) Preferred method to receive the welcome pack and policy guide (only complete if you are the owner on the policy) Post to client Hardcopy CD Send to financial adviser Hardcopy CD Preferred language for communication English Afrikaans Insurable interest/reason for assurance arital status arried Single Divorced Widowed Date of marriage arital contract: ANC COP 2. Spouse Title Initials Surname irst name(s) (as per identity document) ID or passport number Sex Date of birth (please include copy of passport) Contact number 3. Owner/purchaser (only if different from principal life) Company name Title Initials Surname irst name(s) (as per identity document) ID or passport number (please include copy of passport) Telephone (H) ax address Postal address Residential address Work address Registration number Date of birth (W) Cellphone Preferred method to receive the welcome pack and policy guide (only complete if you are the owner on the policy) Post to client Hardcopy CD Send to financial adviser Hardcopy CD Preferred language for communication English Afrikaans Relationship to principal life Insurable interest/reason for assurance Please note that this policy will always be issued as a non-conforming policy. 4. Child details (must be identical to the Discovery Health Plan) Child irst name Surname ID number or passport number Date of birth Sex Adult dependant details (must be identical to the Discovery Health Plan) Adult irst name Surname ID number or passport number Date of birth Sex Page 2 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06

3 3. Education details 1. Principal life (Please complete principal and spouse details irrespective of whether benefits have been selected for the spouse, to determine the highest socio-economic rating). Highest educational qualification: No matric atric 3-year diploma 3+ year diploma 3-year degree 3+ year degree Professional Total income per month (gross) Occupation Current employer R Industry Proportion of time spent on: Administration Supervision anual Travel 2. Spouse Highest educational qualification: No matric atric 3-year diploma 3+ year diploma 3-year degree 3+ year degree Professional Total income per month (gross) Occupation Current employer Proportion of time spent on: R Administration Supervision Industry anual Travel 4. Beneficiary nomination Beneficiary nomination details (to be nominated by the owner of the policy) Beneficiaries to whom the proceeds will be paid on the death of the principal life Initials Surname ID number or passport number Relationship to owner/purchaser Add up to Pre-existing exclusion Pre-existing exclusion: All claims arising from any physical defects, illnesses, bodily injuries or diseases that the life assured has suffered from, was aware of, or has received medical treatment or advice for, or any circumstances or risk factors, which have or are likely to have an adverse effect on the health of the life assured, in the three years before commencement of this policy, are excluded for the first three years from commencement or reinstatement of this benefit, after which the client will receive full cover, unless a permanent underwriting exclusion has been placed on the policy. Health Plan Protector disclaimer questions*: 1. Have you ever been refused cover, offered cover on special terms or received compensation for injury, sickness, Principal Yes No dread disease or disability or are there any circumstances that may affect the risk relating to the proposed cover? Spouse Yes No If yes, please provide details: Principal Spouse 2. Are you aware of or have you ever suffered from any of the following: Principal Spouse (if applicable) Cancer Yes No Yes No Organ transplant Yes No Yes No Heart failure or any heart surgery Yes No Yes No Heart attack within last three years Yes No Yes No Stroke or any chronic neurological disorder, eg multiple sclerosis Yes No Yes No Disability quadriplegia, paraplegia, hearing loss, loss of vision, loss of limb, loss of speech Yes No Yes No Liver disease Yes No Yes No Kidney failure Yes No Yes No Emphysema or chronic obstructive pulmonary disease Yes No Yes No Any lung surgery Yes No Yes No HIV-positive or AIDS Yes No Yes No Diabetes mellitus with any form of complication Yes No Yes No Page 3 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06

4 5. Pre-existing exclusion (continued) Principal Spouse (if applicable) Psychiatric disorder, eg schizophrenia, major depression Yes No Yes No Back surgery within the last two years or ongoing severe pain Yes No Yes No Do you participate in hazardous pursuits, eg micro-lighting, motor racing etc? Yes No Yes No Yes to any of the above, please provide details Principal Spouse *If any of these disclaimer questions are answered yes, the Health Plan Protector might be declined principle life spouse Date 6. Payment by debit order Private debit order Name of bank Branch Account type Current Transmission Savings Branch code Name of accountholder Account number Telephone number I agree to advise Discovery in writing of any changes that may occur. I warrant that the information supplied is true and correct. accountholder Please note: The first debit will be presented at date of acceptance unless a future date of commencement has been stipulated. Company debit order Name of company Employer number Please note: This option is only available to you if you are part of a company that pays Health Plan Protector premiums on behalf of its employees. 7. Health Plan Protector details Date of commencement Y Y Y Y 0 1 Please note that the date of commencement will be the same as for the Discovery Health Plan if you simultaneously applied for both products. Please select your option Health Dividends Health und edical Waiver Benefit payment term amily composition Benefit options Occurrence of the event on: 5 years Disability/Severe Illness Principal only 10 years Death/Disability/Severe Illness 1st of principal and spouse** ** If this option is selected, please note that the total premium will be the sum of the two relevant premiums for the principal and spouse, reflected in the tables below: Smoker status Principal life Smoker smoker Spouse Smoker smoker If non-smoker rates selected, have you smoked in the last 12 months? Principal life Yes No Spouse Yes No The following tables display the premium rates that will apply based on the plan you selected above: Health Plan Death/Disability/Severe Illness Death/Disability/Severe IIlness Benefit option Executive Executive Table A Table B Comprehensive Comprehensive, Priority, ed, Umed Classic, Umed Value and LA Comprehensive Table C Table D Core Saver, Core, KeyCare Core, KeyCare Plus, LA Active, LA Core and LA ocus and all other InHouse schemes Table E Table Disability/Severe Illness Benefit option Page 4 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06

5 7. Health Plan Protector details (continued) Death/Severe Illness/Capital Disability Severe Illness/Capital Disability Executive plan Executive plan Table A Table B R282 R307 R332 R357 R382 R406 smoker R245 R255 R270 R282 R294 R307 Smoker R332 R357 R382 R406 R431 R454 Smoker R255 R270 R282 R294 R307 R319 R357 R394 R419 R444 R469 R494 smoker R282 R307 R332 R357 R380 R406 Smoker R481 R531 R556 R581 R606 R630 Smoker R344 R382 R406 R431 R454 R481 Comprehensive plans Comprehensive plans Table C Table D R226 R246 R265 R285 R305 R325 smoker R196 R204 R216 R226 R236 R246 Smoker R265 R285 R305 R325 R345 R363 Smoker R204 R216 R226 R236 R246 R256 R285 R315 R335 R355 R375 R395 smoker R226 R246 R265 R285 R304 R325 Smoker R385 R425 R445 R465 R484 R504 Smoker R275 R305 R325 R345 R363 R385 Death/Severe Illness/Capital Disability Core/Saver plans Table E Severe Illness/Capital Disability Core/Saver plans Table R198 R219 R227 R238 R248 R256 smoker R172 R180 R190 R198 R209 R219 Smoker R219 R227 R238 R248 R256 R268 Smoker R180 R190 R198 R209 R219 R227 R248 R268 R286 R305 R324 R344 smoker R190 R209 R219 R227 R238 R248 Smoker R297 R315 R334 R354 R373 R391 Smoker R227 R256 R268 R277 R286 R295 Note: = member Premium rates are expressed in rands Page 5 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06

6 8. DiscoveryCard If you apply for a DiscoveryCard, you can make full use of the various health, lifestyle, credit and leisure benefits offered by Vitality. 1. Principal life Are you an existing DiscoveryCard holder? Yes No Would you like to apply for a DiscoveryCard as the principal cardholder? Yes No Would you like to apply for a DiscoveryCard as a secondary cardholder on an existing account? Yes No 2. Spouse Are you an existing DiscoveryCard holder? Yes No Would you like to apply for a DiscoveryCard as the principal cardholder? Yes No Would you like to apply for a DiscoveryCard as a secondary cardholder on an existing account? Yes No 3. Application for a new DiscoveryCard Name Surname Race White Black Asian Coloured Consent from spouse if the marriage is in community of property Yes Number of children (natural and legally adopted) Property capacity Owner Lodger Tenant No If you are a property owner please stipulate Property bonded Bond free Country of permanent residence South Africa Other Are you undergoing debt counselling Yes No Please note your application for a DiscoveryCard is subject to credit approval. or the DiscoveryCard conditions or our pricing guide, please visit Please note that the conditions and pricing guide may vary from time to time. Please note: This application form does not constitute a sale of the DiscoveryCard. An accredited consultant will contact you to complete the process after the commencement of the LIE PLAN. If you want to apply for a DiscoveryCard you must submit a certified copy of your green South African bar coded identity document as well as a document providing your residential address (less than three months old) together with this application. Please note that your DiscoveryCard application may be delayed if these documents are not submitted with your application form. I am aware that my financial adviser is able to provide me with the factual information regarding information about the DiscoveryCard, but that he or she is unable to provide me with the financial advice about this product. applicant spouse Page 6 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06

7 9. Conditions/undertaking and warranties 1. I hereby consent to the collection, collation, processing, storage and disclosure of my personal information in Sections 1-5 and 8 of this application for the purpose of underwriting and administering this policy and for the assessment of claims under this policy. 2. Do you consent to the collection, collation, processing, storage and disclosure of your personal information in Sections 1, 2, 4 and 8 of this application form for any purpose relating to this product (or use of your DiscoveryCard if applicable) and to enable Discovery, any third party provider, inancial Services Provider or its representative (accredited or authorised by Discovery ) to advise you of or offer to you any enhanced benefits or new products which become available from time to time which you may become entitled to or qualify for as a policyholder, provided that this consent may be withdrawn if you request such withdrawal to subscription@discovery.co.za? Yes No 3. Complaints If you have received inadequate information or unsatisfactory service or have complaints relating to the advice received, please contact our Compliance Department at DL_Compliance@discovery.co.za Should your complaint not be resolved to your satisfaction by Discovery, you may contact the undermentioned bodies for assistance: Long-term Insurance Ombudsman The AIS Ombud The Honourable Judge Brian Galgut Charles Pillai Private Bag X45, Claremont 7735 Boabab House, Eastwood Office Park, Sunclare Building, 3rd loor Lynnwood Road, Pretoria 21 Dreyer Street, Claremont, c/o inancial Services Board Cape Town 7700 PO Box 74571, Lynnwood Ridge / / info@ombud.co.za info@faisombud.co.za Client authority a. Disclosure of all relevant facts You warrant that all information provided by you in terms of any application for assurance, reinstatement of a lapsed contract or membership of any und will form the basis of the contract. In this regard you warrant that: You have disclosed all material information; and you will continue to disclose material information between the date of this application and either the commencement date of the policy, or the acceptance of risk by Discovery, whichever occurs last. You understand that any breach of your warranty may result in the contract being declared void by Discovery or the terms on which the policy was issued being rectified by Discovery and contributions paid being used to offset expenses incurred by Discovery. b. Acceptance of standard terms and conduct of business The contract to be issued to you will incorporate the standard terms, conditions, and rules for the type of policy and benefits applied for. A contract will not commence and no liability whatsoever will attach to Discovery as a result of this contract unless and until you have paid the first premium and your express written notice of acceptance of the risk has been given by Discovery. You agree that Discovery may deal with any and all transactions relating to your contract electronically, including transactions previously requiring written authority or confirmation. You are aware that in terms of the inancial Advisory and Intermediary Services Act of 2002 (AIS), you may request a copy of any document that you or someone on my behalf admits to Discovery that pertains to this proposal. c. Confirmation of contract terms Unless you object in writing within 30 days from the issue date of the contract, you will be deemed to have accepted the contents of the policy document. In the event of your objecting, Discovery reserves the right to adjust the terms of the contract. Thereafter, you agree that the client authority, the policy document and Discovery s computer records, together with any amendments to them will form the basis and record of your contract. d. Guaranteed Insurability Benefit Please note that should you cease to be a member of Discovery Health and/or Vitality, Discovery will automatically convert your standalone Health Plan Protector to a LIE PLAN providing you with, Severe Illness and Capital Disability Benefits cover for the same premium, without any additional evidence of health or insurability. The new LIE PLAN will take on all existing health loadings and/or exclusions that applied to the Health Plan Protector. e. Consent to medical tests and disclosure of information To facilitate the assessment of the risk and the consideration of any claims for benefits under a policy related to this or any other proposal for assurance made by you, or in respect of you or any member of your family as an assured or to ensure the efficient administration of your policy, you irrevocably authorise Discovery to: Obtain from any person, including Discovery Health, Discovery Health edical Scheme and Vitality HealthStyle (Pty) Ltd (including DiscoveryCard), any information including any private health, wellness and lifestyle medical information including HIV status which Discovery deems necessary at application stage and on an ongoing basis; and Share with other assurers that information and any other information contained in this proposal or in any related policy or other document either directly or through a database operated by or for assurers as a group, at any time (even after your death) and in such detailed, abbreviated or coded form as may from time to time be decided by Discovery or by the operators of such a database; Provide the value of your Health und (as defined by Discovery ) to your financial adviser; Provide to your appointed financial adviser policy information necessary to ensure the efficient administration of your policy and to ensure compliance with our obligations as they may be applicable to you or your policy as set out in the Long-term Insurance Act (52 of 1998), the Policyholder Protection Rules (PPR) and the inancial Advisory and Intermediary Services Act, 2002 or any other applicable legislation; To obtain from any person, any information that Discovery needs in connection with this application or the policy. I also authorise and instruct such person to give the said information to Discovery; I acknowledge that I cannot cancel this authorisation and that it will endure after my death; Obtain from any person your contract details and to verify your identity and any personal information with any reputable service provider during the assessment of an application, claim and servicing and administration of your policy. You hereby authorise and instruct such person or reputable service provider to give such information to Discovery or conduct such information for Discovery as the case may be; Discovery Holdings and/or irstrand Bank Limited to use your ICA verification documents, if you apply for another product that requires ICA verification. Page 7 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06

8 9. Conditions/undertaking and warranties (continued) f. smokers declaration If you have applied for non-smoker rates, you declare that you have not smoked tobacco in any form during the past 12 months and have no intention of smoking tobacco at any time in the future. If you do commence smoking you must advise Discovery within one year and your contributions and benefits will be adjusted accordingly. If you fail to advise Discovery, you understand that Discovery is entitled to reduce any benefits by 20 in addition to the smoker rates adjustment. g. Payment You authorise Discovery to collect due contributions and charges from and to pay any amounts due to you into the bank account specifi ed by you. You undertake to advise Discovery of any changes in these details. Discovery will not be held responsible for incorrect banking details supplied by the owner of the policy. In accordance to New Business rules, where no commencement date is indicated and this policy is activated between the 1st and 10th of the month, and your chosen debit order date is after the 10th a double debit order will be deducted from your specifi ed bank account, on your debit order date as indicated. In terms of the Prevention of Organised Crime Act of 1998, you confirm that the funds with which any payment is or will be made to Discovery in terms of this policy are derived from a lawful source. You declare that you will be willing to answer any questions with regard to the origin of such funds and to provide additional information when it may be required by Discovery. You instruct Discovery to pay the sales fees/commission to your financial adviser as agreed. Signed at (town or city) on main applicant Policy owner spouse 10. inancial adviser details 1. Principal financial adviser Commission split inancial adviser house Discovery Consulting Services branch and consultant Bank reference number (if applicable) Work number (andatory for all ABSA and NB intermediaries) Cell number financial adviser Date signed ICA declaration I warrant and confirm that I have established and verified the identities of the applicant(s), insured lives, premium payer(s), agent(s) and cessionary(ies), where applicable, with regard to this application/contract in terms of the inancial Intelligence Centre Act, 2001, read together with the oney Laundering Regulations. Yes No OR I have seen the original and attached the required ICA documents to this application Yes No 2. inancial adviser Commission split inancial adviser house Discovery Consulting Services branch and consultant Bank reference number (if applicable) Work number (andatory for all ABSA and NB intermediaries) Cell number financial adviser Date signed ICA declaration I warrant and confirm that I have established and verified the identities of the applicant(s), insured lives, premium payer(s), agent(s) and cessionary(ies), where applicable, with regard to this application/contract in terms of the inancial Intelligence Centre Act, 2001, read together with the oney Laundering Regulations. Yes No OR I have seen the original and attached the required ICA documents to this application Yes No Page 8 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06

9 10. inancial adviser details 3. inancial adviser Commission split inancial adviser house Discovery Consulting Services branch and consultant Bank reference number (if applicable) Work number financial adviser (andatory for all ABSA and NB intermediaries) Cell number Date signed ICA declaration I warrant and confirm that I have established and verified the identities of the applicant(s), insured lives, premium payer(s), agent(s) and cessionary(ies), where applicable, with regard to this application/contract in terms of the inancial Intelligence Centre Act, 2001, read together with the oney Laundering Regulations. Yes No OR I have seen the original and attached the required ICA documents to this application Yes No 4. inancial adviser Commission split inancial adviser house Discovery Consulting Services branch and consultant Bank reference number (if applicable) Work number financial adviser (andatory for all ABSA and NB intermediaries) Cell number Date signed ICA declaration I warrant and confirm that I have established and verified the identities of the applicant(s), insured lives, premium payer(s), agent(s) and cessionary(ies), where applicable, with regard to this application/contract in terms of the inancial Intelligence Centre Act, 2001, read together with the oney Laundering Regulations. Yes No OR I have seen the original and attached the required ICA documents to this application Yes No Page 9 of 9 Discovery is an authorised financial services provider Registration number 1966/003901/06