Application for Reinstatement

Transcription

1 Application for Reinstatement Completion instructions For owners of adult plans: Read section 3, then Complete sections 1, 2 and 7. Mark boxes with ( ) where appropriate, otherwise use block letters. Leave a box between words. telephone underwriting May we phone or you if we need to clarify any details contained in this statement? No Yes If Yes, please provide contact details. Telephone number For owners of child plans: Read section 3, then Complete sections 1, 2, 6 and 7. For Insured Persons: Read section 3, then Complete sections 4 and 8. If you are the second Insured Person, complete Sections 5 and 8. Preferred contact time 8am-10am 10am-12pm 12pm-2pm 2pm-4pm 4pm-6pm Any Preferred contact day Monday Tuesday Wednesday Thursday Friday Any address 1 To be completed by the plan owner(s) Plan Number(s) Please state why the plan lapsed. If more than 2 owners, please use an additional Application for Reinstatement First Owner Address Business hours phone number Home phone number Mobile phone number Second Owner Address Business hours phone number Home phone number Mobile phone number AMP Life Limited ABN A1 of (11/07)

2 2 To be completed by the Plan Owner(s) If more than 2 Insured Persons please use an additional Application for Reinstatement. First Insured Person Second Insured Person Privacy Your privacy is important to AMP. Our primary purpose in collecting personal information from you is to enable us to establish and manage this product one of AMP s broad range of financial services. The information may be used for related purposes, such as to provide you with ongoing information about the range of financial services that may be useful for your financial needs. These may include investment, retirement, financial planning, banking, credit, life and general insurance products and enhanced customer services that may be made available by us, other members of the AMP Group, or by your financial planner. We need this information in order to establish and manage this product and, if you choose not to provide the information necessary to process your application, we may not be able to process it. We usually disclose information of this kind to: Other companies in the AMP Group. Your employer if you are part of an employer sponsored plan. The financial planner or broker responsible for the plan, (if any). The owner of your plan. External service suppliers who supply administrative, financial or other services to assist the AMP Group in providing AMP financial services. Anyone you have authorised. When health information is collected, additional restrictions apply. Our primary purpose for obtaining this information is to assess the application for new or additional insurance from AMP. We may also use this information for directly related purposes such as deciding whether we need more information; arranging reinsurance; assessing future applications for new or altered insurance; assessing and administering claims. We will generally collect health information from someone else, such as a doctor, with consent. We need this information to assess the insurance application and, if consent is not provided, we may not be able to process the application. We may disclose this type of health information to: If your insurance is part of a superannuation fund, the trustee of that fund. The financial planner or broker responsible for the plan, (if any). AMP s reinsurers. Medical practitioners. Any person AMP considers necessary to assist in either the assessment of claims under your plan or the resolution of complaints. Anyone you have authorised. Aspects of your health information may be provided to the owner of your plan in resolving terms of acceptance or if the standard Plan Rules are varied. The AMP Privacy Plan Statement sets out the AMP Group s policies on management of personal information. A copy may be obtained from AMP, your AMP financial planner or our website. Under the National Privacy Principles, you may access personal information about you held by the AMP Group and you may let us know if you think any of it is inaccurate, incomplete or out of date. There are some limited situations, that are set out in the National Privacy Principles, where you will not have this right. You can contact us by calling Your Duty of Disclosure You must answer all the questions in this Application completely and accurately. This helps us to decide whether to provide the insurance, how much to charge and whether any special rules should apply. You must also tell us anything else you think may be relevant to our decision about insuring you, or anything a reasonable person in the circumstances could be expected to know would be relevant to our decision. This duty continues until we advise you that we have accepted your insurance and agreed to provide you with cover. If you don t tell us what we need to know to complete our assessment of risk, we may be able to treat your cover as if it never existed and pay nothing, or keep your cover going but reduce the amount we pay. A2 of 10

3 4 insured person 1 To be completed by the first insured person, or the owner of a child s plan which has Suspension of Premium Benefit. Existing insurance details Are you applying for, or do you have in force, any personal insurance with AMP or with any other insurer? No Yes If Yes, please provide details of other insurances, and current or prior proposals, insuring your life: Name of insurer Life cover Total & Permanent Disablement cover Trauma cover Monthly disability (income) cover Disability Type Is this cover to be cancelled? AMP Life Limited $ $ $ $ If Yes give policy No. $ $ $ $ If Yes give policy No. $ $ $ $ If Yes give policy No. * Temporary salary continuance cover ** Income protection cover *** Business overheads insurance cover Important Note: Your application will be considered on the understanding that if you intend to cancel any existing cover, that you will do so on acceptance of this application. Failure to do so may render invalid a claim on your AMP plan. If this application is to replace a current AMP plan, the plan to be replaced will cease and a new plan will start. a. What is your state of health? b. Do you have AIDS or any AIDS-related disorders or have you had a positive blood test for the HIV antibody? No Yes c. During the last 5 years, have you: i) Consulted, been examined, treated or received advice from any medical practitioner, psychologist, No Yes physiotherapist, chiropractor, or other health professional; or had any test (blood tests, ECG, X-Ray, mammogram, etc). (If Yes, please give full particulars below of each instance.) If additional space is required, attach a separate sheet of paper. Condition/ name first started of last symptoms No. of occurrences Time off work Details/ symptoms Complications/ ongoing effects / / / / / / / / Name and address of doctor or hospital ii) Been in a hospital, clinic or nursing home? (if Yes, give details) No Yes iii) Been advised to have an operation? (If Yes, give details) No Yes d. During the last 5 years have you ever been refused a life, disablement, crisis/critical illness, sickness No Yes crisis/critical illness, sickness and accident plan or Superannuation cover or accepted with an increased premium or been offered insurance on terms other than those for which you applied? (If Yes, give details) e. Have you smoked tobacco or any other substance during the past 12 months? No Yes (If Yes, give details of substance and daily quantity) If Yes, please advise the type of product Quantity per: Day Week Month A3 of 10

4 Occupation, activities, residence and income details (this section must be completed for all applicants) a. Current occupation b. Type of industry c. What is the average amount of time you work? hours per week weeks per year d. Does your occupation involve manual labour? (If Yes, give details) No Yes e. Have you any intention of changing your occupation or taking extended leave of absence in the future? No Yes (If Yes, give details) f. In the last 3 years have you taken part, or in the future do you intend to take part, in any hazardous No Yes activity or any organised sport? Examples of such activities are flying (other than as a fare-paying passenger), motor sports, diving, abseiling, rock climbing and football. (If Yes, give details) Activity type Amateur/ professional Hours/events per year Please provide any other information that may help us understand your involvement in the above activities. g. Do you have any definite plans to travel or reside overseas, or are you currently residing overseas? No Yes (If Yes, give details including dates, countries to be visited, length of stay, reason.) Financial For cases where the sum insured is $500,000 or greater, or for Flexible Lifetime Protection Income Protection Insurance. a. What has been your net income for the last 2 years (ie gross income or revenue, less business expenses)? Year ending 30/06/20 Year ending 30/06/20 b. Has your business traded profitably for the last 2 years? No Yes Note: Further financial evidence to support this application may be required. Agreement and declaration a. I declare that the answers to all the questions and the written information provided in this Application and any separate statements are true, correct and complete, whether or not they are in my own handwriting, and that I have kept back nothing which might cause the insurer to decide that the insured person is a greater risk to insure. b. I acknowledge that I have received and read the notice of Your Duty of Disclosure in Section 3. I understand that my duty to disclose information continues even after this Application has been completed, until AMP notifies me in writing that it has accepted my Application for Reinstatement. I understand that, if I fail to comply with this duty, the reinstatement may be cancelled or the cover may be altered. c. I authorise any doctor, hospital or other health service provider that I have or may attend to release details of my personal medical history, including referrals to or treatment by other practitioners, to AMP. The purpose is to allow AMP to assess my application for new/additional/reinstated insurance (as applicable) and assess any claim that might arise. I understand that, under Government Privacy legislation, I may access a copy of these reports from AMP. I have been advised by AMP of the ways this information may be used, and to whom it may be disclosed, and approve those purposes. d. AMP is authorised to divulge to their reinsurers any information that AMP has acquired with regard to me. Signature of insured person (or owner if a child s plan) AMP Life Limited ABN A4 of 10

5 5 insured person 2 To be completed by the first insured person, or the owner of a child s plan which has Suspension of Premium Benefit. Existing insurance details Are you applying for, or do you have in force, any personal insurance with AMP or with any other insurer? No Yes If Yes, please provide details of other insurances, and current or prior proposals, insuring your life: Name of insurer Life cover Total & Permanent Disablement cover Trauma cover Monthly disability (income) cover Disability Type Is this cover to be cancelled? AMP Life Limited $ $ $ $ If Yes give policy No. $ $ $ $ If Yes give policy No. $ $ $ $ If Yes give policy No. * Temporary salary continuance cover ** Income protection cover *** Business overheads insurance cover Important Note: Your application will be considered on the understanding that if you intend to cancel any existing cover, that you will do so on acceptance of this application. Failure to do so may render invalid a claim on your AMP plan. If this application is to replace a current AMP plan, the plan to be replaced will cease and a new plan will start. a. What is your state of health? b. Do you have AIDS or any AIDS-related disorders or have you had a positive blood test for the HIV antibody? No Yes c. During the last 5 years, have you: i) Consulted, been examined, treated or received advice from any medical practitioner, psychologist, No Yes physiotherapist, chiropractor, or other health professional; or had any test (blood tests, ECG, X-Ray, mammogram, etc). (If Yes, please give full particulars below of each instance.) If additional space is required, attach a separate sheet of paper. Condition/ name first started of last symptoms No. of occurrences Time off work Details/ symptoms Complications/ ongoing effects / / / / / / / / Name and address of doctor or hospital ii) Been in a hospital, clinic or nursing home? (if Yes, give details) No Yes iii) Been advised to have an operation? (If Yes, give details) No Yes d. During the last 5 years have you ever been refused a life, disablement, crisis/critical illness, sickness No Yes crisis/critical illness, sickness and accident plan or Superannuation cover or accepted with an increased premium or been offered insurance on terms other than those for which you applied? (If Yes, give details) e. Have you smoked tobacco or any other substance during the past 12 months? No Yes (If Yes, give details of substance and daily quantity) If Yes, please advise the type of product Quantity per: Day Week Month A5 of 10

6 Occupation, activities, residence and income details (this section must be completed for all applicants) a. Current occupation b. Type of industry c. What is the average amount of time you work? hours per week weeks per year d. Does your occupation involve manual labour? (If Yes, give details) No Yes e. Have you any intention of changing your occupation or taking extended leave of absence in the future? No Yes (If Yes, give details) f. In the last 3 years have you taken part, or in the future do you intend to take part, in any hazardous No Yes activity or any organised sport? Examples of such activities are flying (other than as a fare-paying passenger), motor sports, diving, abseiling, rock climbing and football. (If Yes, give details) Activity type Amateur/ professional Hours/events per year Please provide any other information that may help us understand your involvement in the above activities. g. Do you have any definite plans to travel or reside overseas, or are you currently residing overseas? No Yes (If Yes, give details including dates, countries to be visited, length of stay, reason.) Financial For cases where the sum insured is $500,000 or greater, or for Flexible Lifetime Protection Income Protection Insurance. a. What has been your net income for the last 2 years (ie gross income or revenue, less business expenses)? Year ending 30/06/20 Year ending 30/06/20 b. Has your business traded profitably for the last 2 years? No Yes Note: Further financial evidence to support this application may be required. Agreement and declaration a. I declare that the answers to all the questions and the written information provided in this Application and any separate statements are true, correct and complete, whether or not they are in my own handwriting, and that I have kept back nothing which might cause the insurer to decide that the insured person is a greater risk to insure. b. I acknowledge that I have received and read the notice of Your Duty of Disclosure in Section 3. I understand that my duty to disclose information continues even after this Application has been completed, until AMP notifies me in writing that it has accepted my Application for Reinstatement. I understand that, if I fail to comply with this duty, the reinstatement may be cancelled or the cover may be altered. c. I authorise any doctor, hospital or other health service provider that I have or may attend to release details of my personal medical history, including referrals to or treatment by other practitioners, to AMP. The purpose is to allow AMP to assess my application for new/additional/reinstated insurance (as applicable) and assess any claim that might arise. I understand that, under Government Privacy legislation, I may access a copy of these reports from AMP. I have been advised by AMP of the ways this information may be used, and to whom it may be disclosed, and approve those purposes. d. AMP is authorised to divulge to their reinsurers any information that AMP has acquired with regard to me. Signature of insured person (or owner if a child s plan) AMP Life Limited ABN A6 of 10

7 6 Statement of health (child) Personal Statement relating to the health of the insured child for a child s plan. a. What is the present state of the child s health? b. Has the child had any illness or met with any accident since the above plan was effected? (If Yes, state the date, No Yes nature and duration of illness or injury and treatment received.) c. Please state the name and address of family doctor, or attending doctor if the answer to question b is Yes. d. Has there been any other change in circumstances since the plan was effected which may affect the risk, No Yes apart from those noted in b above? (If Yes, please give details) Agreement and declaration (Owner of the child s plan) a. I declare that the answers to all the questions and the written information provided in this Application and any separate statements are true, correct and complete, whether or not they are in my own handwriting, and that I have kept back nothing which might cause the insurer to decide that the insured person is a greater risk to insure. b. I acknowledge that I have received and read the notice of Your Duty of Disclosure in Section 3. I understand that my duty to disclose information continues even after this Application has been completed, until AMP notifies me in writing that it has accepted my Application for Reinstatement. I understand that, if I fail to comply with this duty, the reinstatement may be cancelled or the cover may be altered. c. I authorise any doctor, hospital or other health service provider that I have or may attend to release details of my personal medical history, including referrals to or treatment by other practitioners, to AMP. The purpose is to allow AMP to assess my application for new/additional/reinstated insurance (as applicable) and assess any claim that might arise. I understand that, under Government Privacy legislation, I may access a copy of these reports from AMP. I have been advised by AMP of the ways this information may be used, and to whom it may be disclosed, and approve those purposes. d. AMP is authorised to divulge to their reinsurers any information that AMP has acquired with regard to me. Signature of the owner of the child s plan 7 Agreement and declaration To be completed by the plan owner(s) I apply for reinstatement of my plan and declare and acknowledge as follows: a. The answers to all the questions and the written information provided in this application and any separate statements are true, correct and complete, whether or not they are in my own handwriting, and I have kept back nothing which might cause the insurer to decide that the insured person is a greater risk to insure. b. I have received and read the notice of Your Duty of Disclosure from Section 3. I understand that my duty to disclose information continues even after I have completed this application, and right up until AMP notifies me in writing that it has accepted my application for reinstatement. I understand that, if I fail to comply with this duty, the reinstatement may be cancelled or the cover may be altered. c. AMP may, in considering my application for reinsurance, apply conditions to the plan including restarting or resuming any waiting periods that AMP considers necessary in its discretion. Plan owner 1 signature Plan owner 2 signature AMP Life Limited ABN A7 of 10

8 8 Authority for Medical Report To be completed and signed by the insured person Doctor/Health Service Provider, I hereby authorise you to release at any time details of my personal medical history, including referrals to or treatment by other Practitioners, to AMP Life Limited ABN The purpose is to allow AMP to assess my application for new/additional/ reinstated insurance (as applicable) and assess any claim that might arise. Under Government Privacy legislation, I may access a copy of your report from AMP. Furthermore, I have been advised by AMP of the ways this information may be used and to whom it may be disclosed, and approve those purposes. A photocopy of this authorisation shall be as valid as the original. Name of insured person Address of insured person Signature of insured person 8 Authority for Medical Report To be completed and signed by the insured person Doctor/Health Service Provider, I hereby authorise you to release at any time details of my personal medical history, including referrals to or treatment by other Practitioners, to AMP Life Limited ABN The purpose is to allow AMP to assess my application for new/additional/ reinstated insurance (as applicable) and assess any claim that might arise. Under Government Privacy legislation, I may access a copy of your report from AMP. Furthermore, I have been advised by AMP of the ways this information may be used and to whom it may be disclosed, and approve those purposes. A photocopy of this authorisation shall be as valid as the original. Name of insured person Address of insured person Signature of insured person A8 of 10

9 AMP Life PO Box 300 Parramatta NSW 2124 AMP Life PO Box 300 Parramatta NSW 2124 A9 of 10

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