Group Accident and Health Personal Accident and Sickness Proposal Form vbl0318

Transcription

1 Group Accident and Health Personal Accident and Sickness Proposal Form vbl0318

2 IMPORTANT NOTICES Please read these Important Notices before completing this application. Your Duty of Disclosure For Insureds who are not a natural person, before You enter into an insurance contract, You have a duty to tell Us anything that You know, or could reasonably be expected to know, may affect Our decision to insure You and on what terms. You have this duty until We agree to insure You. You have the same duty before You renew, extend, vary or reinstate an insurance contract. You do not need to tell Us anything that: reduces the risk We insure You for; or is common knowledge; or We know or should know as an insurer; or We waive Your duty to tell Us about. If You do not tell Us something If You do not tell Us anything You are required to, We may cancel Your contract or reduce the amount We will pay You if You make a claim, or both. If Your failure to tell Us is fraudulent, We may refuse to pay a claim and treat the contract as if it never existed. Individuals If You are the Insured and a natural person, a different duty of disclosure to the one set out above applies to You. Please contact Your intermediary so that You can be informed of the duty of disclosure that applies to You. Privacy In this Privacy Statement the use of: We, Us and Our means certain Underwriters at Lloyd s and Pen Underwriting; You and Your means the Insured; unless specified otherwise. We are committed to protecting Your privacy. We are bound by the obligations of the Privacy Act 1988 (Cth). This sets out basic standards relating to the collection, use, storage and disclosure of personal information. The primary purpose for Our collection, use, storage and disclosure of Your personal information is to enable Us to provide insurance services to You. We need to collect, use and disclose Your personal information (which may include sensitive information) in order to consider Your application for insurance and to provide the cover You have chosen, administer the insurance and assess any claim. You can choose not to provide Us with some of the details or all of Your personal information, but this may affect Our ability to provide the cover, administer the insurance or assess a claim. We may disclose the personal information We collect to third parties who assist Us in providing the above services, such as related entities, distributors, agents, insurers, reinsurers and service providers. Some of these third parties may be located outside of Australia. In all instances where personal information may be disclosed to third parties who may be located overseas, We will take reasonable measures to ensure that the overseas recipient holds and uses Your personal information in accordance with the consent provided by You and in accordance with Our obligations under the Privacy Act 1988 (Cth). Personal Information will be obtained from individuals directly where possible and practicable to do so. Sometimes it may be collected indirectly (e.g. from Your insurance intermediary or co- Insureds). If You provide personal information for another person You represent to Us that: You have the authority from them to do so and it is as if they provided it to Us; You have made them aware that You will or may provide their personal information to Us, the types of third parties We may provide it to, the relevant purposes We and the third parties We disclose it to will use it for, and how they can access it. If it is sensitive information We rely on You to have obtained their consent on these matters. If You have not done or will not do either of these things, You must tell Us before You provide the relevant information. You are entitled to access Your personal information and request correction if required. In dealing with Us, You consent to Us using and disclosing Your personal information as set out in this statement. This consent remains valid unless You alter or revoke it by giving written notice to Pen Underwriting s Privacy Officer. However, should You choose to withdraw Your consent, We may not be able to provide insurance services to You. Pen Underwriting s Privacy Policy which is available at or by calling Pen Underwriting, sets out how: Pen Underwriting protects Your personal information; You may access Your personal information; You may correct Your personal information held by Us; You may complain about a breach of the Privacy Act 1988 (Cth) or Australian Privacy Principles and how Pen Underwriting will deal with such a complaint. If You would like additional information about privacy or would like to obtain a copy of the Privacy Policy, please contact Pen Underwriting s Privacy Officer by: Post: PO Box 230 Collins Street West VIC 8007 Phone: compliance.au@penunderwriting.com You can download a copy of Pen Underwriting s Privacy Policy by visiting General Insurance Code of Practice We proudly support the General Insurance Code of Practice. The purpose of the Code is to raise the standards of practice and service in the general insurance industry. For further information on the Code, please visit Page 1 of 6

3 IMPORTANT NOTICE This Proposal Form is to be completed by the Proposed Insured for and on behalf of all Insured Persons to be covered by this insurance Please answer all questions in full. Where appropriate, tick the Yes or No box that best indicates your reply. If there is insufficient space provided, please provide further information in the Additional Information section. All attached documents form part of this Proposal. This Proposal is for New Business Renewal - Policy Number (if known) is:... If Section 2 Sickness Benefits are required, our Individual Personal Accident and Sickness Proposal Form is to be completed by each Insured Person to be covered under this insurance. 1. Proposer(s) Name:... Postal Address:... Postcode:... Phone:... Fax:... Contact Person: Insured Persons Please show all persons or group of persons to be covered under each category. Category A:... Category B:... Category C:... Category D: Nature of the Insured s business (e.g. manufacturing, retail etc) Page 2 of 6

4 4. Personal Accident and Sickness Cover Please show the Benefit Amounts requested for the Insured Persons Part A Part B Part C Part D Part E Part F Lump Sum Benefits Lump sum 100% amount: $... Is Part A to be restricted to cover for Event 1 Accidental Death only? Yes No Weekly Benefits - Injury 85% of weekly salary Maximum Benefit Amount $... Or lesser weekly amount required is $... Other Benefit Period of:... weeks (if less than 104 weeks) Injury Resulting in Surgery N/A Weekly Benefits - Sickness Weekly Benefit Amount (limited to 85% of weekly salary): 85% of weekly salary (Maximum Benefit Amount) $... Or lesser weekly amount required is $... Other Benefit Period is:... weeks (if less than 104 weeks) Sickness Resulting in Surgery N/A Injury Resulting in Fractured Bones Lump sum 100% amount: $... Part G Injury Resulting in Loss or Damage to Teeth Lump sum 100% amount: $ Excess Period Excess Period is the time before we pay a weekly Benefit Amount and is a minimum of fourteen (14) days. If a longer Excess Period is preferred, please show the number of days for each Category of Insured Persons. Category A: Category B: Category C: Category D: 6. Scope of Cover Scope of Cover is the period of time during each day that the Insured Person is to be covered for (eg. 24 hours / 35days working hours only, outside working hours, etc). Please specify what Scope of Cover is required for each Category of Insured Persons. Category A: Scope of Cover:... Category B: Scope of Cover:... Category C: Scope of Cover:... Category D: Scope of Cover:... Page 3 of 6

5 9. Are you aware of any accidents, sickness, illness or disease that has prevented any of the persons to be covered under this policy from attending to their usual occupation or duties for periods of more than fourteen consecutive days during the past three years? Yes No If Yes, please provide details: 10. Has an application for insurance for the Insured ever been declined or accepted on special terms for group life, accident or sickness / illness insurance, or has any Insurer every cancelled or declined to renew such a policy? Yes No If Yes, please provide details: 11. Does the Insured currently have an insurance policy against accident, sickness, illness or disease for any of the Insured Persons? Yes No If Yes, please provide details: 12. Is this proposed insurance intended to replace a current insurance policy? Yes No Page 4 of 6

6 DECLARATION I/We declare that: I/We have read and understood the Insurance Product Disclosure Statement and Policy. I/We am authorised by each of the Proposed Insured(s) to sign this Proposal. The statements in this Proposal are true and complete and no material information has been withheld. I/We have read and understood the Important Notices accompanying this Proposal. I/We have diligently made all necessary enquiries in order to comply with the duty of disclosure. I/We have read the Pen Underwriting Privacy Statement on this Proposal and consent to the use, disclosure and obtaining of personal information about the Insured for the purposes shown in the Privacy Statement. Where I/We have provided information about another individual, that individual has been made aware of that fact and of the Pen Underwriting Privacy Statement. I/We acknowledge that Pen Underwriting relies on the information and representations of this Proposal and otherwise made by me or on my behalf in relation to this insurance. Expect where indicated to the contrary, I/We understand that any statement made in this Proposal will be treated as a statement made by all persons to be insured. I/We undertake to notify Pen Underwriting of any material alteration to the information contained in this Proposal prior to inception of the proposed insurance. I/We understand that no insurance is in place until such time as Pen Underwriting has confirmed acceptance of the proposed insurance. Signature:... Date:... Full Name:... Title:... Page 5 of 6

7 ADDITIONAL INFORMATION If there is inadequate space to answer our Questions, please use this Additional Information section. Please also attach any brochures, promotional pamphlets or other publications relevant to this application for insurance. This information forms part of the application and is subject to the above declaration. QUESTION ANSWER Page 6 of 6