Group Income Protection Member s continuation statement (employee)

Transcription

1 Group Protection - Benefits Management Team Legal & General Assurance Society Limited Legal & General House, Kingswood, Tadworth, Surrey KT20 6EU. Telephone: We may record and monitor calls. Group Income Protection Member s continuation statement (employee) Name of scheme Group policy number G Member s name It is important that you complete and return this form to Legal & General or any person or organisation acting on their behalf as soon as possible. Please answer all the questions. If your incapacity prevents you from completing this form you may ask someone to help you. Part A - Personal details Address (only complete if any of the details have changed) Telephone number Landline/mobile Postcode Part B - Occupation details When answering questions 1 to 8 you should note that your employer s scheme can make provision for the payment of a reduced benefit for members who are able to return to work in a lesser capacity. 1 Are you able to undertake any part of your normal job? Yes No If yes, please provide full details. 2 Do you anticipate returning to your normal job either full or part time? Yes No If yes, please state whether full time or part time, and when. 3 Do you intend seeking alternative employment either full or part time? Yes No If yes, please state whether full time or part time, and when. 4 Have you undergone, or intend undergoing, any form of retraining or rehabilitation? Yes No If yes, please give details.

2 5 Are you aware of any adaptations that could be made to your workplace that would help you to return to work either full or part time? Yes No If yes, please give full details. 6 How often do you talk to your employer? 7 Have you consulted your employer about ongoing employment? Yes No If yes, please give full details. 8 Have you consulted your doctor(s) about your future employability? Yes No If yes, please give full details. Part C - Financial details 1 Are you currently undertaking any work for which you get paid? Yes No If yes, please give details of your employment together with total earnings per annum. Earnings 2 Are you receiving benefit payments from the Benefits Agency? Yes No If yes, please give full details. 3 Are you receiving payment from any source or claiming or intending to claim from any Yes No other company, society or insurer, including credit protection insurance? If yes, please state. Source When will When will Monthly payment start? payment end? amount 4 Please give details and amount(s) of any pension(s) being received or applied for. Source Start date Monthly amount

3 5 Are you or do you intend seeking compensation or instigating any legal Yes No proceedings against any person as a result of your incapacity? Part D - Details of your incapacity Please do not assume that we will write to your doctor, it is your responsibility to complete this form properly. 1 On what date did you last undertake any part of your occupation? 2 Please describe your illness or injury. / / 3 a) What symptoms of your incapacity prevent you from working? b) How often are you restricted by these symptoms and how long does it last and what do you do to alleviate them? 4 Name, address and telephone number of your General Practitioner (GP) and date last consulted. / / Postcode Telephone no.: 5 What medication are you currently taking? Please include dosage and describe any side effects. 6 What treatment have you received in connection with your incapacity and is this providing relief from your symptoms? 7 Please provide the name(s) and address(es) of the consultant(s) attended in connection with this condition. Name and department: Address: Postcode: Date: Name and department: Address: Postcode: Date: Name and department: Address: Postcode: Date:

4 8 CAPABILITIES WALKING How far (in metres) are you able to walk on a level surface without stopping? Metres Please describe the factors that prevent you from walking further than the distance stated above. RISING/SITTING Do you require assistance to sit and rise from a raised chair with arms? Yes No If yes, please describe the assistance that you require. DEXTERITY Please describe any restriction you have with writing legibly using a pen or pencil, and/or typing using a keyboard with either hand. COMMUNICATION Please describe any difficulties or restrictions you have in hearing (with or without hearing or other aid). When communicating with other people, please describe how well you are able to understand them. When communicating with other people, please describe how well they understand you. EYESIGHT Are you registered blind or partially sighted? Please tick the appropriate box and enclose a copy of your registration certificate as applicable. Blind Partially sighted Neither

5 9 What is your a) Height b) Weight 10 What weight can you lift, pull or push? 11 Please describe your current functional ability by writing a number from 1 to 5 in each of the boxes below. 5= no reduction 4= slightly reduced function 3= moderately reduced function 2= very reduced function 1= no function at all Right shoulder Right arm Right hand Climbing stairs Climbing Working at ladders heights Left shoulder Left arm Left hand Bending Lifting/carrying Prolonged sitting Walking Standing Kneeling Driving Reaching Outdoor work above shoulders in all weathers Speech Hearing Vision Mental function Exposure to Self care cold/heat 12 Please describe your hobbies, pastimes and general interests. Which of these are you still able to do? 13 What household or D.I.Y tasks are you able to do? 14. Do you visit friends and socialise? Note The benefit you are receiving is paid under your employer's Group Income Protection scheme and is not an early retirement pension. As such it will be subject to regular reviews and will cease if the conditions of the policy insuring the scheme are not fulfilled.

6 Part E - Access to Medical Reports Your rights under the Access to Medical Reports Act (1988) and the Access to Personal Files and Medical Reports (Northern Ireland) Order (1991) and the Isle of Man Access to Health Records and Reports Act (1993). In connection with this review for Group Income Protection, Legal & General, or any person or organisation acting on their behalf, may require a medical report from a doctor who has attended or is currently attending you. You are required to give your consent to the application for a report from a doctor by signing the statement on the next page. You can withhold consent, although this could affect Legal & General's ability to assess your entitlement to benefit. If you do give your consent, you can also indicate whether or not you wish to see the report before it is supplied to Legal & General or any person or organisation acting on their behalf. If you do, they will inform the doctor of your wishes and you will then have 21 days to arrange with the doctor to see it before he passes it on. If you do see the report, the doctor cannot pass it on until he has your consent to do so. You can ask him, in writing, to amend any part of the report which you consider incorrect or misleading and you can ask him to attach a statement of your views on any part of the report he refuses to amend. The doctor does not have to let you see any part of the report that he considers would be likely to cause serious harm to the physical or mental health of yourself or others, or would indicate the doctors intentions towards you. He/she also does not have to let you see any part that would be likely to disclose information about, or the identity of, another person who has supplied information about you, unless that person has consented or the information relates to, or has been supplied by a health professional caring for you. If the doctor does not let you see any part of the report he must notify you of that fact. Once the report has been supplied, the doctor must keep a copy of it for six months and you are entitled to inspect it or receive a copy of it during that time. The doctor is entitled to charge you a fee for any copy report supplied to you.

7 Part F Declaration I declare that I am the person referred to in the preceding pages and that I have read the replies to all the questions on this form and that to the best of my knowledge and belief the information is true and that I have not withheld any material facts (facts likely to influence the assessment of continued benefit payment). Consent I consent to the information contained in this statement and any other information obtained in connection with this assessment of eligibility for benefit payment (including medical or health details) from any doctor or relevant person either now or in the future ( Personal Data ) being used in connection with this review and any subsequent review of eligibility for benefit payment. I understand that this may involve Legal & General, or any person or organisation acting on their behalf (managing agents), discussing this information with my employer and I consent to them passing the Personal Data to my employer, its professional advisers and any other person involved in the assessment and management of the entitlement to benefits. I also understand that insurers share information to prevent fraudulent claims via an Association of British Insurers (ABI) register and I understand that some of the information that I supply on this form will be placed on the register and made available to participating insurers, a list of which is available on request from the ABI. Access to Medical Reports I understand my rights (see Part E of this form) under the Access to Medical Reports Act (or its equivalent in Northern Ireland and Isle of Man) and agree that a copy of this authority shall have the validity of the original. I consent to Legal & General, or any person or body acting on their behalf, seeking information in connection with this review of eligibility for benefit payment, from any doctor who has at any time attended me, or any other relevant person, and I authorise the provision of such information, together with hospital and GP s medical records. If Legal & General, or any person or organisation acting on their behalf (managing agents), request any reports that are subject to the terms of the Access to Medical Reports Act (1988): I do not want to see the report before it is sent to Legal & General or its managing agents. I want to see the report before it is sent to Legal & General or it s managing agents. (please tick as appropriate) I understand that the issue of this form is not an admission of continued liability. Signature Date / / If your incapacity prevents you from signing this declaration yourself, the person who helped you to complete this form should sign it on your behalf in the space provided below. Signed on behalf of the member Date / / Name Relationship to member Reason for signing on behalf of the person described in this form

8 Legal & General Assurance Society Limited, Registered in England No Registered office: One Coleman Street, London EC2R 5AA. A member of the Association of British Insurers W /08 NONGASD