APPLICATION FORM. Outstanding choice

Transcription

1 APPLICATIO FORM Outstanding choice underwritten by Hollard Life Altrisk is a division of Hollard Life Assurance, an authorised financial services provider (FSP 17697). Tel Fax

2 While we don t want to blow our own trumpet, we do stand out from the crowd in the world of risk insurance. Through a philosophy of simplicity and accessibility, and unique underwriting expertise, Altrisk approaches life insurance differently. Founded in 1999 by a team who saw the need to provide cover for those traditionally declined, Altrisk, with the backing of Hollard, today provides a suite of risk insurance products for clients across the board. The Altrisk product range of benefits is reinsured primarily through the Hannover Re Group, the third largest reinsurance group in the world. Through our entrepreneurial ability, clear focus and specialisation in risk, Altrisk has achieved success by delivering a superior level of service, competitive product range and a promise to make life insurance easier. Together with the support of Hollard and Hannover you can take comfort knowing that with Altrisk your interests are in expert hands. While Hollard Life provides your cover, Altrisk is responsible for all administration, and communication regarding your policy. Reference to Altrisk/Hollard Life in the application form refers to the relevant party in that instance.

3 Life insured information Title Initials First name Surname Former surname Gender M F Language English Afrikaans ID no Date of birth M M D D Postal address Tel no. Cell no. Section 1 Life insured details Section Are you self employed? 2.2 What is your present occupation? 2.3 Since when have you been in this occupation? 2.4 What industry do you work in? 2.5 Previous occupations in the last 5 years (with dates) M M D D 2.6 Describe your duties in terms of percentages Admin Supervisory (manual labour) Travel Manual 2.7 Education ot matriculated Matriculated Diploma Degree Post Grad. 2.8 Give details of qualifications 2.9 Are you a qualified member of a professional organisation? If yes, state the name of the professional organisation 2.10 Give details of income Current year Previous year Current year Previous year Monthly income Insured Spouse Present taxable salary pm pm pm pm Present taxable commission pm pm pm pm Monthly after tax income pm pm pm pm Other income pm pm pm pm 2.11 Have you ever been declared insolvent? If yes, have you been rehabilitated? 2.12 Have you made or do you intend to make an application for debt review in terms of the ational Credit Act? 2.13 Are you aware of any retrenchment process currently underway at your current employer? 2.14 Are you employed by a family-owned business where you are a member of the same family? 2.15 Do you have any intention of leaving South Africa (permanently or temporarily for a period of 1 month or more)? If yes, which countries do you intend to travel to? 2.16 Do you participate in a high risk occupation, sport, hobby or pastime which may expose you to a higher than average risk of injury (e.g. motorised speed contests, aviation, diving, bungee jumping)? If yes, give details Policy owner information (if different to life insured) Section 3 Policy owner 1 Policy owner 2 Title Initials Title Initials ame Surname Other Date of birth ID/Reg no. M M D D M M D D Relationship to life insured Postal address Tel no. Cell no. English Afrikaans Policy owner tax status atural person Company deductible Company non-deductible Ver 20 page 1 of 6

4 Policy information Section 4 Reason for insurance Personal Bond cover Asset cover Buy and sell Partnership Contingent liability Loans Key person Estate duty Other 4.1 Should a disability business endorsement be applied? 4.2 Is this application linked to any other application (joint life, buy and sell, etc.)? If yes, supply the name/s of the life insured/s. 4.3 What date would you like your policy to commence on: M M 0 1 our policy document and future communications (where possible) will be ed to the policy owner. Documents unavailable electronically will be posted. Beneficiary information 5.1 Should the applicable proceeds for this policy be paid to the estate of the policy holder? Section 5 If no is selected above complete the table below with your beneficiary details First name/s Surname Date of birth ID no. Relationship to life insured % Spouse and children nomination for additional funeral benefit Relationship to life insured (tick) First name/s Surname Date of birth ID no. Spouse Child Other insurance information Section 6 Complete the table below with the benefit amounts of other existing insurance policies on the life insured s life. Include any policies not yet finalised but exclude policies being replaced with this application. Insurance with other insurers Life cover Occupational disability Functional impairment Physical impairment Disability income short term (payment period less than or equal to 24 months) Disability income long term (payment period longer than 24 months) Critical illness Total personal sum insured Total business assurance sum insured Total group life sum insured Protection of existing insurance OTE: Replacement of existing insurance is generally to the disadvantage of the owner because it involves duplication of initial costs charged to the policy. Is this proposal to replace the whole or any part of your existing insurance with any insurer (whether replacement is to occur immediately or to replace an insurance discontinued in the past 4 months or within the next 4 months)? If yes, the intermediary must discuss and complete the Replacement Policy Advice Record and attach it to this proposal form. Does this proposal constitute a replacement of a risk policy or an investment policy with a recurring premium investment that will lead to or has led to the levying/deduction of a termination charge (causal event charges and administration charges) of more than 15% of the replaced policy s fund value? Refer to the definitions in Part 3 of the Regulations to the Long-Term Insurance Act, 1998 (commission regulations) Ver 20 page 2 of 6

5 Personal details Section Height (without shoes) cm 7.2 Weight (in normal clothes) kg 7.3 Has your weight changed by more than 3kg during the past year due to any of the following: Pregnancy Diet Exercise Illness Stress Depression Unknown 7.4 Do you consume any alcoholic liquor? If yes, state quantity and type per week. 7.5 Have you habitually taken more in the past? If yes, state quantity and type per week. 7.6 Have you ever received medical advice to reduce or discontinue your liquor consumption? If yes, state reason, name and telephone number of doctor concerned. 7.7 Have you ever been charged with drunken driving? 7.8 Do you currently smoke, or have you smoked in the last 12 months? If yes, what and how much do you smoke per day? 7.9 Have you ever received medical advice to reduce or discontinue smoking? If yes, state reason, name and telephone number of the doctor concerned Have you ever consumed, injected or smoked any illegal narcotics? 7.11 Are you a member of a medical aid? If yes, give details. Life insured information Section 8 Do you have, or have you ever had, trouble with or disorders of: 8.1 our heart or circulation (e.g. blood pressure, chest pains, heart murmur, palpitations, rheumatic fever, stroke)? 8.2 our lungs (e.g. persistent cough, shortness of breath, tuberculosis, asthma, bronchitis)? 8.3 our digestive system or liver (e.g. recurrent indigestion, ulcers, bleeding from the bowel, hepatitis, gallstones)? 8.4 our kidneys, bladder or reproductive organs (e.g. stones, infections, bilharzia, prostate problems)? 8.5 our nervous system (e.g. concussion, paralysis, fits, blackouts, depression, anxiety, persistent headaches)? 8.6 our eyes (excluding errors of refraction), ears, nose or throat (e.g. deafness, ear discharge)? 8.7 our skeletal joints or muscles (e.g. rheumatism, arthritis, back or neck trouble, gout)? 8.8 our glands or blood (e.g. diabetes, thyroid, spleen, bleeding disorder, leukaemia)? 8.9 Growths (e.g. cancer, carcinoma-in-situ (pre-cancer), lump or tumour of any kind)? 8.10 Have you sought medical advice during the past 5 years in connection with any symptom or condition, or been a patient in a hospital or nursing home or undergone any medical examination (including ECG, X-ray examination, pap-smear, mammogram, colonoscopy, gastroscopy or ultrasound with abnormal results or specialised laboratory tests) not mentioned above? 8.11 Are you taking, or have you ever taken drugs, tranquillisers or any other medicines in any form for a continuous period of more than two weeks? 8.12 Have you ever been tested for or received medical advice, counselling or treatment in connection with AIDS, or any infection by one of the AIDS viruses, or any sexually transmitted disease (e.g. hepatitis B, gonorrhoea, syphilis or any venereal disease)? 8.13 Have you been for any genetic testing or received counselling for genetic testing in the past 5 years? 8.14 Has any proposal for life, sickness, accident or disability insurance on your life ever been declined, deferred, withdrawn or accepted at special terms or on special rates? If yes, please provide a policy number and company name In the last 2 years, have you ever been absent from work for a continuous period of more than 1 month as a result of an accident or sickness? If yes, state nature of incapacity, duration and dates Are you aware of any other health or other factors (past or present), which may influence the risk attached to this policy? If yes, list these below: Ver 20 page 3 of 6

6 If you answered yes to any of the questions above, supply full details below Section 8 continued Question o. ature & duration of complaint or symptom Date ame & address of attending doctor/hospital Date of last symptoms 8.17 ame, physical address and telephone number of your usual doctor: Tel no. Fax no. Postal address 8.18 ame and address of any other medical attendant who has acted in this capacity during the last 5 years: 8.19 I hereby give consent to Altrisk/Hollard Life to release copies of and discuss my medical information with my doctor 8.20 I hereby give consent to Altrisk/Hollard Life to discuss my medical information with my financial advisor Family history Section 9 Has any immediate family member, i.e. father, mother, brother, sister, ever been diagnosed with or died from any of the diseases, events or procedures below (under the age of 60)? 9.1 Raised cholesterol, angina, heart attack, coronary bypass surgery, angioplasty, stent, stroke, transient ischaemic attack, hypertension or diabetes 9.2 Cancer, carcinoma-in-situ (pre-cancer) or tumour of any kind (please specify the site and type of cancer in the table below) 9.3 Kidney disease (excluding kidney stones) 9.4 Multiple sclerosis, Huntington s chorea, motor neurone disease, Parkinson s disease, haemochromotosis Complete the table below for each family member where applicable Family member Condition diagnosed from above list Age Additional information Ver 20 page 4 of 6

7 Declaration by life insured and policy owner Section 10 I declare that I have fully considered and understood each page of this application and the related documents and that the statements and responses given in this application and all documents that I have signed or will sign in connection with this application are true and complete. I, the life insured, declare that I am willing to undergo testing for HIV (Human Immunodeficiency Virus) and I understand the implications of a positive test and have been given the opportunity to read the counselling information. I indemnify Altrisk/Hollard Life and their directors, consultants and employees against any claim made against them as a result of such test. I agree that this application and declaration together with all relevant documents that have been or will be signed by me/us or any person whose life is to be insured in terms hereof, shall be the basis of the contract between Altrisk/Hollard Life and myself, and that if any material information is withheld the benefits and all monies paid to Altrisk/Hollard Life shall be forfeited. I further agree that should Altrisk/Hollard Life accept this application, such acceptance will be conditional upon there having been no material alteration to the facts on which the decision was based and no illness or injury to the life to be insured between the date of signing this application and the date of acceptance of the policy by Altrisk/Hollard Life. Any such alteration to the facts must be communicated to Altrisk/Hollard Life in writing, and failure to do so may result in repudiation of any future claim. I understand that if the first premium is not paid on or before the first debit order date no cover is provided, or benefits payable for the period from that debit order date until the first premium is received in full by Altrisk/Hollard Life. Accepting that I am thereby curtailing my right of privacy, but to facilitate the assessment of the risks, and the consideration of any claim for benefits, under a policy related to this or any other proposal for insurance made by me, or in respect of me as life insured, at any time (even after my death) and in such detailed, abbreviated or coded form as may from time to time be decided by Altrisk/Hollard Life or by the operators of such database, I irrevocably authorise Altrisk/Hollard Life to: (a) (b) (c) (d) obtain from any person, who I hereby so authorise and request to give, any information which Altrisk/Hollard Life deems necessary; share with other insurers that information and any information contained in this application or in any related policy or other document, either directly or through a database operated by, or for, insurers as a group; obtain and provide to any credit bureau, life insurance or credit providers industry association or other association for an industry in which Altrisk/Hollard Life operates, any information relating to my credit worthiness or any consumer credit related information; and send me any relevant information pertaining to my policy benefits and other benefits Altrisk offers from time to time. Validity of quotation information This application is only valid if the accompanying signed quotation is prepared on the latest Altrisk/Hollard Life quotation program. This application does not create any obligation for Altrisk/Hollard Life until it has been accepted in writing by Altrisk/Hollard Life. Altrisk/Hollard Life will not be liable for any errors and omissions made by the applicant or financial advisor on the signed quotation. Altrisk/Hollard Life will not be held liable for any errors or omissions which may have occurred in the production or completion of this document. If there are any discrepancies between the signed quotation and the policy contract to be issued, the policy contract will prevail. I confirm and accept the quoted information and details of the attached signed quotation with reference number to be a true and complete summary of all the information used in producing the quotation accepted by myself/ourselves. I hereby authorise Altrisk/Hollard Life to automatically accept this application if the change in the attached Illustrative Quote premium is less than 10%. For your protection this form should not be signed until all details have been completed. This form will be deemed to have been completed by you irrespective of who completed the form. Signed at on M M D D Signature (life insured) Signature (owner) Signature (owner) Ver 20 page 5 of 6

8 Debit order authorisation Section 11 OTE: Altrisk/Hollard Life will only process policies where payment is by debit order. (Payments by credit card or cash are not accepted.) Bank Account no. Account holder Branch Branch code Account type Debit date Relationship to life insured I authorise Altrisk/Hollard Life to draw against this account all amounts due in terms of this application. This authorisation is to remain in force until terminated by Altrisk/Hollard Life or myself. I accept that Altrisk/Hollard Life may debit my account on a date other than that specified. If there are insufficient funds in the nominated account to meet the premium payment due, Altrisk/Hollard Life is entitled to track my account and present the instruction for payment as soon as sufficient funds are available. Signature of account holder Date M M D D To be completed by the financial advisor Section 12 I hereby declare that I have explained the benefits and obligations arising from this application to the applicant and that they fully understand the consequences of any incorrect information provided in this application. I further declare that I have explained the meaning and implication of the replacement question to the applicant and that the client is fully aware of the possible detrimental consequences of the replacement of an insurance policy. I have also explained the meaning of replacement, that a replacement is potentially prejudicial, the levying/deduction of a termination charge and that where a replacement is considered, the client is legally entitled to comprehensive information regarding the consequences of replacement. I confirm that I have identified the client, policyholder, insured life, premium payer and cessionary, where applicable, and verified his/her/their details on this contract under the requirements of section 21 of the Financial Intelligence Centre Act, o. 38 of I further confirm that, in terms of section 22 of the same act, I have stored all the verification documents. Primary advisor 1 Secondary advisor 2 Full name Brokerage house Commission split % % Broker code Biblife/Pri no. Tel no. Broker consultant Distribution branch Signature otes Ver 20 page 6 of 6

9 Replacement Policy Advice Record (to be completed in consultation with your representative please note that this does not serve as a cancellation of the replaced policy; you must advise the insurer in writing about cancellation of a policy) Annexure 2 ame and surname of policyholder: ID no of policyholder: (or registration no in the case of juristic persons) ame and surname of representative: Full name of FSP (brokerage or insurer): ew policy: Type of policy: Investment or Risk Policy or Proposal number Insurer Policy being replaced: Type of policy: Investment or Risk Policy or Proposal number Insurer 1. Reasons why replacement may not be advisable If you do replace any policy, we want to ensure that you make an informed choice. Please read the following information, carefully and discuss with your representative. ou will pay some charges and fees twice (e.g. commission, underwriting expenses & other initial charges levied by the insurer) initially on the existing policy and once again on the new policy. ou may pay higher premiums for risk (or a bigger part of the premium) on the new policy because you are older now or your health situation might have changed. our new policy may not have the same life cover or premium guarantees as the existing policy. Check the period for which the life cover or other cover amounts are guaranteed before the insurer is entitled to change your premiums or reduce or remove cover.2 our new policy may not have the same investment performance guarantees as the existing policy (if applicable). our new policy may have more exclusions, restrictions or waiting periods particularly if your health has deteriorated. The amount of money that you can withdraw under the new policy may be less (if applicable). A new policy will usually have legal restrictions on access within the first 5 years. ou may lose the tax advantage of your existing policy (if applicable). The surrender value or paid up value of your existing policy may be as low as 65% of the policy value before the change, and could be even less than premiums paid in since unrecovered initial expenses must first be deducted. Check what charges you will be paying on termination of the old policy and see whether the advantages of the new policy will make up for any such charges. The investment risk under the new policy may be higher. Remember that the past performance of a fund or asset manager of a fund is not necessarily an indication of future performance. Page 1 of 2

10 2. Reasons for the change of policy / policies (not required if replacement policy effected as a result of the internet, telephone or direct marketing) 2.1 Did you establish whether the existing / terminated policy could be amended to provide similar benefits to the replacement policy? please print clearly 2.2 If such amendment is / was possible, why do you regard it as appropriate that the terminated policy be replaced by the replacement policy? please print clearly 3. To be completed if the new business was effected via electronic business Was the replacement policy effected as a result of the: Internet Telephone Direct marketing 3.1 Please indicate the date, time of the phone call/negotiation and (if applicable) reference number: Date: Time: Reference: 3.2 There may be more factors regarding replacements that could influence your decision. Do you require any further advice? es o 4. Declaration (compulsory) (signatures compulsory unless the replacement policy was effected as a result of the internet, telephone or direct marketing) Representative I confirm that I have taken all reasonable steps to confirm that the information in this Replacement Policy Advice Records (RPAR) is true and correct. I confirm that in pursuance of my advice to the policyholder to replace the policy (ies) mentioned in this RPAR. I have fully discharged my duties as set out in section 8 (d) of the General Code of Conduct for Authorised Financial Services Providers and their Representatives (the Code) and have retained a record of such advice as required by section 3 of the said Code. Signature: ame: Policyholder I confirm that the representative has fully explained the consequences of the replacement of the policy(ies) mentioned in this Replacement Policy Advice Record and I understand the consequences of such replacement(s). Signature: ame: Date: Contact telephone and /or address: Date: Page 2 of 2

11 Are you covered? Altrisk s range of risk products have been designed to cover most aspects of life. Death Benefits Life Cover Accidental Death Death Income - Basic & Extended Critical Illness Basic Core Comprehensive Comprehensive Cancer Disability Disability Comprehensive Plus Accidental Impairment Core Comprehensive Income Basic Income Replacement Extended Income Replacement Impairment Income Business Overhead Protector Ancillary Benefits Crisis Waiver Flexible Cover Guaranteed Insurability Early Cancer Cover Retrenchment Specialist Benefits Long Term Care Deferred Life HIV Positive Application

12 Altrisk is a division of Hollard Life Assurance, an authorised financial services provider (FSP 17697). Tel I Fax