Application to alter your HomeInvestor outside the mortgage options

Transcription

1 HomeInvestor Application to alter your HomeInvestor outside the mortgage options Important notes Your answers to the questions on this form will be used to assess the application and you must, therefore, answer them fully to the best of your knowledge and belief. Before any alteration comes into force, any changes in the facts contained in the answers given in this application must be notified to Clerical Medical in writing. Clerical Medical reserves the right to amend the terms on which your application may have been accepted or to withdraw acceptance in any event of such change. Part or all of the plan benefits might be forfeited if relevant information were to be withheld. In accordance with the Association of British Insurers policy on genetics and insurance, you do not need to tell us about any genetic test result you have had if this application for insurance, taken together with any other insurance policies you already have for this type of insurance, totals to: 500,000 or less for life assurance 300,000 or less for critical illness. Above these limits, you may need to tell us about certain genetic test results when applying for insurance. We will only be interested in genetic test results where the Government s Genetics and Insurance Committee (GAIC) has approved them for insurers to use. If you think this may apply to you, please ask us for details of the current position. These details are also available from the ABI website at: However, you must tell us if you either have a family history of, are experiencing symptoms of, or are having treatment for, a medical condition including any genetically inherited condition. If you wish to disclose to us a negative genetic test result, which shows that you have not inherited a genetic disorder, we will take this into consideration when assessing your application (providing your clinical geneticist confirms that this test result indicates a reduced risk of developing the inherited disease). You should remember that any person (except for a member of Clerical Medical s staff), who is advising you regarding the plan(s), policy(ies) or contract(s) for which you are applying, is acting for you and not on behalf of Clerical Medical. Any changes could affect the taxation status of your plan. If this is the case we will contact you to let you know. Changes to the plan will not commence until Clerical Medical has issued written confirmation and all conditions contained therein have been complied with. Copies of the completed application and the plan provisions are available on request. The phrase Clerical Medical is used in this form to refer to Scottish Widows Limited.

2 tes to help you complete this form The life assured is the person on whose death or critical illness the sum assured is payable. The investor will be the plan owner and is usually the person who pays the premiums to Clerical Medical. So the life assured and the investor may or may not be the same person. This form is to be used when exercising the following options within your HomeInvestor: 1. You can apply to remove a life assured from your HomeInvestor. Please complete Section 1 of this form. 2. You can apply to add a life assured to your HomeInvestor, provided there will be no more than two lives assured in total. The new life to be assured must complete Sections 2 and You can apply to alter the amount of sum assured at any time outside the mortgage options, and for any reason. Please note any change could affect the taxation status of your plan. If this is the case we will contact you to let you know. Please complete Sections 3 and 5 if you want to increase the level of sum assured. Please complete Section 4 if you want to decrease the level of sum assured. You can make as many alterations as you like to your HomeInvestor with this form. Complete each section that corresponds to the alteration you want to make. You will need to complete a declaration at the back of this form once you have made your alteration(s). There are two declarations: Declaration A to be completed by the life (lives) assured if Section 5 has not been completed. Declaration B to be completed by the life (lives) assured if Section 5 has been completed. 1

3 Please answer questions in CAPITAL LETTERS, and give careful consideration to any declaration before signing it. Details of the existing life (lives) assured Plan number Surname Full forename(s) Surname Full forename(s) of birth Section 1. Removal of a life assured I would like to remove the life assured named below from my HomeInvestor Surname Full forename(s) of birth Signature of remaining life assured and/or investor Please complete Section 2 if you want to add a life assured to your HomeInvestor. If you don t want to make any other changes please complete Declaration A on page 9. Section 2. Addition of a life assured I would like to add the life assured named below to my HomeInvestor The new life to be assured should complete the following: Surname Full forename(s) Address Sex male female Title Mr Mrs Miss Ms Other Postcode Marital status single married/in a registered civil partnership divorced/registered civil partnership dissolved separated widowed/surviving registered civil partner of birth Place of birth For tax purposes are you resident in the UK? 2

4 Section 2. Addition of a life assured (continued) Country of residence (if other than UK) Nationality (list all if more than one) Occupation: Please give full details of your current occupation including job title, the industry you work in and the duties you perform in your job. Please now complete Section 5 Section 3. Option to increase the sum assured This option is for use when you want to increase the amount of sum assured of your plan outside the provisions of the mortgage options. Please alter amount of sum assured to Please refer to your personal illustration. Please note, if included at outset, Critical Illness cover and/or Waiver of Premium cover will automatically be increased to the same level as the new sum assured. Please now complete Section 5 Section 4. Option to decrease the sum assured This option is for use when you want to decrease the sum assured of your plan. Please alter amount of sum assured to Please refer to your personal illustration. Please note, if included at outset, Critical Illness cover and/or Waiver of Premium cover will automatically be decreased to the same level as the new sum assured. Please now complete Declaration A on page 9 Section 5. To be completed by the life (lives) to be assured The life assured must answer these questions if you are: Increasing the amount of cover from Section 3. Adding a life to your plan from Section 2. Please note, only the life to be added needs to answer these questions. 3

5 Doctor of the life (lives) assured Please give the name and address of your current doctor. Name Dr Address Name Dr Address Postcode Postcode Personal details Please the appropriate box and give full details with relevant dates where appropriate. In the last 12 months have you smoked cigarettes? If, what is/was your average consumption? cigarettes Daily Weekly cigarettes Daily Weekly How much alcohol do you drink? 1 unit = a single measure of spirits, one glass of wine, half pint of beer/cider/lager. units each week Height (without shoes) units each week Height (without shoes) Please state your height and weight. Weight (in normal clothes) Weight (in normal clothes) Details of other plans Has any application on your life ever been declined, deferred, or offered on non-standard terms? If, details are: If, details are: Have you ever withdrawn an application before the company advised you of its decision? If, details are: If, details are: Have you applied or do you intend to apply for life assurance or critical illness cover to any other company or have you done so in the last twelve months? If, details are: If, details are: 4

6 Details of other plans (continued) Do you have any existing life assurance or critical illness policies with Clerical Medical or any other insurer? If, please give details of insurer, sum assured and when commenced. If, details are: If, details are: Health and other information Please answer the following questions, stating or by 4 the appropriate box and giving full details and any relevant dates, continuing on a separate sheet of paper if necessary. a) Do you have any current illness, disability, or medical condition, or are you taking drugs, receiving medical advice, or undergoing treatment or investigations? If, the details are: If, the details are: b) During the last five years have you had any mental or physical illness or injury requiring medical attention, excluding colds, influenza and minor injuries? If, the details are: If, the details are: c) Have you ever undergone or been recommended to undergo hospitalisation, an operation, x-ray or any other investigation? If, the details are: If, the details are: Type Type Reason Reason 5

7 Health and other information (continued) d) Have you ever had: i) any disorder or disease of the heart or circulation system, high blood pressure or a stroke? If, the details are: If, the details are: ii) diabetes? If, the details are: If, the details are: iii) any form of cancer, growth or other malignancy? If, the details are: If, the details are: iv) kidney, bladder, urinary, stomach, intestinal or liver disorder? If, the details are: If, the details are: 6

8 Health and other information (continued) v) asthma, bronchitis or any respiratory disorder? If, the details are: If, the details are: vi) anxiety, depression or any psychiatric or nervous disorder? If, the details are: If, the details are: vii) a back problem, spinal trouble, arthritis, rheumatism or any other disorder of the musco-skeletal system? If, the details are: If, the details are: viii) multiple sclerosis, tremor, numbness or double vision, or any form of paralysis? If, the details are: If, the details are: 7

9 Health and other information (continued) ix) any form of eye or ear disorder? If, the details are: If, the details are: x) any disorder of the brain? If, the details are: If, the details are: e) Have two or more of your near relatives (ie parents, brothers or sisters) died or suffered from any of the following before age 65: Heart disease; high blood pressure; diabetes; kidney disease; cancer; multiple sclerosis; any form of eye disease; any form of paralysis; a hereditary/familial disorder such as Huntington s chorea? If, the details are: Age at time Relationship If, the details are: Age at time Relationship f) i) Have you ever tested positive for HIV/ AIDs? If, the details are: If, the details are: ii) Have you ever been treated/tested for a sexually transmitted disease or Hepatitis B or C? If, the details are: If, the details are: Type Type Reason Reason 8

10 Health and other information (continued) iii) Are you awaiting the result of any such tests? g) Have you ever taken any drugs for other than medicinal purposes? If, the details are: If, the details are: h) Have you any intention of journeying abroad or living outside the UK (excluding holidays to rth America or Europe) or have you done so for any period of more than three months in the last five years? If, the details are: If, the details are: Country Country i) Have you any intention of participating in any hazardous activities (for example climbing, motor sport, diving or aviation)? If, the details are: If, the details are: Please now complete Declaration B on page 12 Declaration A to be completed by the life (lives) assured Complete this declaration if you have not completed Section 5. I/We declare that I/we have read and understood the important notes on the cover of this application and that all statements made by me/ us in this application are true and complete to the best of my/our knowledge and belief. I/We have read any answers completed other than in my/our own handwriting and confirm that they are correct. Signature Name in CAPITAL LETTERS Signature Name in CAPITAL LETTERS 9

11 Declaration A to be completed by the life (lives) assured (continued) Data Privacy tice Your personal information will be held by Scottish Widows Ltd which is part of the Lloyds Banking Group. More information on the Group can be found at This privacy notice contains key information about how we will use and share your personal information and the rights you have in relation to this. If you want to know more please access our full privacy notice at or ask us for a copy. We will use your personal information: to provide products and services, manage your relationship with us and comply with any laws or regulations we are subject to (for example the laws that prevent financial crime or the regulatory requirements governing the products we offer). for other purposes including improving our services, exercising our rights in relation to agreements and contracts and identifying products and services that may be of interest. To support us with the above we analyse information we know about you and how you use our products and services, including some automated decision making. You can find out more about how we do this, and in what circumstances you can ask us to stop, in our full privacy notice. Your personal information will be shared within Lloyds Banking Group and other companies that provide services to you or us, so that we and any other companies in our Group can look after your relationship with us. By sharing this information it enables us to better understand our customer s needs, run accounts and policies, and provide products and services efficiently. This processing may include activities which take place outside of the European Economic Area. If this is the case we will ensure appropriate safeguards are in place to protect your personal information. You can find out more about how we share your personal information with credit reference agencies below and can access more information about how else we share your information in our full privacy notice. We will collect personal information about you from a number of sources including: information given to us on application forms, when you talk to us in branch, over the phone or through the device you use and when new services are requested. from analysis of how you operate our products and services, including the frequency, nature, location, origin and recipients of any payments. from or through other organisations (for example card associations, credit reference agencies, insurance companies, retailers, comparison websites, social media and fraud prevention agencies). in certain circumstances we may also use information about health or criminal convictions but we will only do this where allowed by law or if you give us your consent. You can find out more about where we collect personal information about you from in our full privacy notice. We may be required by law, or as a consequence of any contractual relationship we have, to collect certain personal information. Failure to provide this information may prevent or delay us fulfilling these obligations or performing services. The law gives you a number of rights in relation to your personal information including: the right to access the personal information we have about you. This includes information from application forms, statements, correspondence and call recordings. the right to get us to correct personal information that is wrong or incomplete. in certain circumstances, the right to ask us to stop using or delete your personal information. from 25th May 2018 you will have the right to receive any personal information we have collected from you in an easily re-usable format when it s processed on certain grounds, such as consent or for contractual reasons. You can also ask us to pass this information on to another organisation. You can find out more about these rights and how you can exercise them in our full privacy notice. We may also collect personal information about other individuals who you have a financial link with. This may include people who you have joint accounts or policies with such as your partner/spouse, dependents, beneficiaries or people you have commercial links to, for example other directors or officers of your company. 10

12 Declaration A to be completed by the life (lives) assured (continued) We will collect this information to assess any applications, provide the services requested and to carry out credit reference and fraud prevention checks. You can find out more about how we process personal information about individuals with whom you have a financial link in our full privacy notice. In order to process your application we may supply your personal information to credit reference agencies (CRAs) including how you use our products and services and they will give us information about you, such as about your financial history. We do this to assess credit worthiness and product suitability, check your identity, manage your account, trace and recover debts and prevent criminal activity. We may also continue to exchange information about you with CRAs on an ongoing basis, including about your settled accounts and any debts not fully repaid on time, information on funds going into the account, the balance on the account and, if you borrow, details of your repayments or whether you repay in full and on time. CRAs will share your information with other organisations, for example other organisations you ask to provide you with products and services. Your data will also be linked to the data of any joint applicants or other financial associates as explained above. You can find out more about the identities of the CRAs, and the ways in which they use and share personal information, in our full privacy notice. The personal information we have collected from you and anyone you have a financial link with may be shared with fraud prevention agencies who will use it to prevent fraud and money laundering and to verify your identity. If fraud is detected, you could be refused certain services, finance or employment. Further details of how your information will be used by us and these fraud prevention agencies, and your data protection rights, can be found in our full privacy notice. If you apply to us for insurance, we may pass your details to the relevant insurer and their agents. If a claim is made, any personal information given to us, or to the insurer, may be put onto a register of claims and shared with other insurers to prevent fraudulent claims. It is important that you understand how the personal information you give us will be used. Therefore, we strongly advise that you read our full privacy notice, which you can find at or you can ask us for a copy. If you have any questions or require more information about how we use your personal information please contact us using You can also call us on If you feel we have not answered your question Lloyds Banking Group has a Group Data Privacy Officer, who you can contact on and tell us you want to speak to our Data Privacy Officer. We would like to keep you up to date on products and offers that may be of interest to you. Please select how you would like to hear from us below. These choices won t affect any necessary information we need to send you such as statements and, don t worry, you can change your mind and update your preferences at any time. SCOTTISH WIDOWS WEBSITES You may see relevant messages when you log in to our online services. If you choose no, you may still see messages, but they will not be tailored to you. POST DEVICE NOTIFICATIONS As we develop mobile applications you ll receive relevant notifications to your mobile device TEXT MESSAGES PHONE By saying yes, you are giving consent for Scottish Widows to use your personal information to send you relevant offers and information about our products. Scottish Widows includes the following legal entities: Scottish Widows Ltd, Scottish Widows Unit Trust Managers Limited, Scottish Widows Administration Services Limited and HBOS Investment Fund Managers Limited. Occasionally we will send you selected offers from other companies within Lloyds Banking Group that may be relevant to you. 11

13 Declaration A to be completed by the life (lives) assured (continued) SCOTTISH WIDOWS WEBSITES You may see relevant messages when you log in to our online services. If you choose no, you may still see messages, but they will not be tailored to you. POST DEVICE NOTIFICATIONS As we develop mobile applications you ll receive relevant notifications to your mobile device TEXT MESSAGES PHONE By saying yes, you are giving consent for Scottish Widows to use your personal information to send you relevant offers and information about our products. Scottish Widows includes the following legal entities: Scottish Widows Ltd, Scottish Widows Unit Trust Managers Limited, Scottish Widows Administration Services Limited and HBOS Investment Fund Managers Limited. Occasionally we will send you selected offers from other companies within Lloyds Banking Group that may be relevant to you. Declaration B to be completed by the life (lives) assured Complete this declaration if you have completed Section 5. I/We have received the Important notes on the cover of this application. For your own benefit and protection, please read each of the statements in that section before you sign this application. Clerical Medical will rely on them when administering your contract. If you do not understand any point, please let us know. I/We have read any answers completed other than in my/our own handwriting and confirm that they are correct. I/We consent to Clerical Medical seeking information from any doctor who at any time has attended me/us, concerning anything which affected my/our physical or mental health, or seeking information from any insurance office to which an application has been made for life assurance on my/our life/lives and I/we authorise the giving of such information. I/We have had written notice of my/our statutory rights under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (rthern Ireland) Order 1991, and I/We do not* wish to see any report before it is sent to Clerical Medical, I/We understand that I/we shall retain the right to see, within the next six months, any report produced. I/We agree that a copy of this consent shall have the validity of the original. I/We further consent to Clerical Medical obtaining a medical report after my/our death(s) from any Medical Practitioner who has at any time attended me/us. Such consent shall endure for an indefinite period following my/our death(s). * If you wish to see your medical report please delete not ; this is likely, however, to delay the processing of your application. Confirming your identity Under current regulations we are required to verify the identity of our customers. In order to meet this requirement and for the prevention and detection of fraud, we will access information from a credit reference agency* to confirm your identity. They will authenticate your name and address (and date of birth), which involves checking the details you supply against those held on any databases that the company carrying out the checks on our behalf (or any similar company) has access to. This includes information from the Electoral Register. We will use scoring methods to authenticate your identity. Our search will not be used by lenders or insurers when assessing lending or insurance risks. We may also pass information to financial and other organisations involved in money laundering and fraud prevention to protect ourselves and our customers from theft and fraud. If you give us false or inaccurate information and we suspect fraud, we will record this and share this information with other organisations. If you provide us with information about another person, we will treat this as confirmation that they have appointed you to act for them to consent to the processing of their personal data. This means that you have informed them of our identity and the purpose for which their personal data will be processed, namely to verify their name and address (and date of birth). Where Clerical Medical receives notification affecting the legal ownership of the plan, or the appointment of an attorney under a Power of Attorney or other circumstances where there are new parties associated with the contract, the same process as set out above will apply. 12

14 Declaration B to be completed by the life (lives) assured (continued) Please note that if we cannot confirm your name and address by using a credit reference agency we may contact you to ask you to supply certain documents to verify this information. If you ask, we will tell you which credit reference agency we have used so you can get a copy of your details from them * Please note we only use this agency to verify identity to fulfil anti-money laundering regulations and not to check credit worthiness. Data Privacy tice Your personal information will be held by Scottish Widows Ltd which is part of the Lloyds Banking Group. More information on the Group can be found at This privacy notice contains key information about how we will use and share your personal information and the rights you have in relation to this. If you want to know more please access our full privacy notice at or ask us for a copy. We will use your personal information: to provide products and services, manage your relationship with us and comply with any laws or regulations we are subject to (for example the laws that prevent financial crime or the regulatory requirements governing the products we offer). for other purposes including improving our services, exercising our rights in relation to agreements and contracts and identifying products and services that may be of interest. To support us with the above we analyse information we know about you and how you use our products and services, including some automated decision making. You can find out more about how we do this, and in what circumstances you can ask us to stop, in our full privacy notice. Your personal information will be shared within Lloyds Banking Group and other companies that provide services to you or us, so that we and any other companies in our Group can look after your relationship with us. By sharing this information it enables us to better understand our customer s needs, run accounts and policies, and provide products and services efficiently. This processing may include activities which take place outside of the European Economic Area. If this is the case we will ensure appropriate safeguards are in place to protect your personal information. You can find out more about how we share your personal information with credit reference agencies below and can access more information about how else we share your information in our full privacy notice. We will collect personal information about you from a number of sources including: information given to us on application forms, when you talk to us in branch, over the phone or through the device you use and when new services are requested. from analysis of how you operate our products and services, including the frequency, nature, location, origin and recipients of any payments. from or through other organisations (for example card associations, credit reference agencies, insurance companies, retailers, comparison websites, social media and fraud prevention agencies). in certain circumstances we may also use information about health or criminal convictions but we will only do this where allowed by law or if you give us your consent. You can find out more about where we collect personal information about you from in our full privacy notice. We may be required by law, or as a consequence of any contractual relationship we have, to collect certain personal information. Failure to provide this information may prevent or delay us fulfilling these obligations or performing services. The law gives you a number of rights in relation to your personal information including: the right to access the personal information we have about you. This includes information from application forms, statements, correspondence and call recordings. the right to get us to correct personal information that is wrong or incomplete. in certain circumstances, the right to ask us to stop using or delete your personal information. from 25th May 2018 you will have the right to receive any personal information we have collected from you in an easily re-usable format when it s processed on certain grounds, such as consent or for contractual reasons. You can also ask us to pass this information on to another organisation. You can find out more about these rights and how you can exercise them in our full privacy notice. 13

15 Declaration B to be completed by the life (lives) assured (continued) We may also collect personal information about other individuals who you have a financial link with. This may include people who you have joint accounts or policies with such as your partner/spouse, dependents, beneficiaries or people you have commercial links to, for example other directors or officers of your company. We will collect this information to assess any applications, provide the services requested and to carry out credit reference and fraud prevention checks. You can find out more about how we process personal information about individuals with whom you have a financial link in our full privacy notice. In order to process your application we may supply your personal information to credit reference agencies (CRAs) including how you use our products and services and they will give us information about you, such as about your financial history. We do this to assess credit worthiness and product suitability, check your identity, manage your account, trace and recover debts and prevent criminal activity. We may also continue to exchange information about you with CRAs on an ongoing basis, including about your settled accounts and any debts not fully repaid on time, information on funds going into the account, the balance on the account and, if you borrow, details of your repayments or whether you repay in full and on time. CRAs will share your information with other organisations, for example other organisations you ask to provide you with products and services. Your data will also be linked to the data of any joint applicants or other financial associates as explained above. You can find out more about the identities of the CRAs, and the ways in which they use and share personal information, in our full privacy notice. The personal information we have collected from you and anyone you have a financial link with may be shared with fraud prevention agencies who will use it to prevent fraud and money laundering and to verify your identity. If fraud is detected, you could be refused certain services, finance or employment. Further details of how your information will be used by us and these fraud prevention agencies, and your data protection rights, can be found in our full privacy notice. If you apply to us for insurance, we may pass your details to the relevant insurer and their agents. If a claim is made, any personal information given to us, or to the insurer, may be put onto a register of claims and shared with other insurers to prevent fraudulent claims. It is important that you understand how the personal information you give us will be used. Therefore, we strongly advise that you read our full privacy notice, which you can find at or you can ask us for a copy. If you have any questions or require more information about how we use your personal information please contact us using You can also call us on If you feel we have not answered your question Lloyds Banking Group has a Group Data Privacy Officer, who you can contact on and tell us you want to speak to our Data Privacy Officer. We would like to keep you up to date on products and offers that may be of interest to you. Please select how you would like to hear from us below. These choices won t affect any necessary information we need to send you such as statements and, don t worry, you can change your mind and update your preferences at any time. SCOTTISH WIDOWS WEBSITES You may see relevant messages when you log in to our online services. If you choose no, you may still see messages, but they will not be tailored to you. POST DEVICE NOTIFICATIONS As we develop mobile applications you ll receive relevant notifications to your mobile device TEXT MESSAGES PHONE By saying yes, you are giving consent for Scottish Widows to use your personal information to send you relevant offers and information about our products. Scottish Widows includes the following legal entities: Scottish Widows Ltd, Scottish Widows Unit Trust Managers Limited, Scottish Widows Administration Services Limited and HBOS Investment Fund Managers Limited. Occasionally we will send you selected offers from other companies within Lloyds Banking Group that may be relevant to you. 14

16 Declaration B to be completed by the life (lives) assured (continued) SCOTTISH WIDOWS WEBSITES You may see relevant messages when you log in to our online services. If you choose no, you may still see messages, but they will not be tailored to you. POST DEVICE NOTIFICATIONS As we develop mobile applications you ll receive relevant notifications to your mobile device TEXT MESSAGES PHONE By saying yes, you are giving consent for Scottish Widows to use your personal information to send you relevant offers and information about our products. Scottish Widows includes the following legal entities: Scottish Widows Ltd, Scottish Widows Unit Trust Managers Limited, Scottish Widows Administration Services Limited and HBOS Investment Fund Managers Limited. Occasionally we will send you selected offers from other companies within Lloyds Banking Group that may be relevant to you. Signature Name in CAPITAL LETTERS Signature Name in CAPITAL LETTERS 15

17 The Access to Medical Reports Act 1988, The Access to Personal Files and Medical Reports (rthern Ireland) Order 1991 and The Access to Health Records and Reports (Isle of Man) Act We may need to get medical reports to support your application. Before we can ask any doctor that you have consulted to fill in a report, we need your permission under the appropriate Act detailed above. Your rights under the appropriate Act are as follows. You do not need to give your permission, but if you do not, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance. You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to keep the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us. If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date. If you think that any part of the report is not correct or is misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him or her to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report, or any part of it, if he or she feels that it would cause physical or mental harm to you or others. The medical report your doctor fills in asks about the following: Your current health; Any care, medication or treatment you are currently receiving. The results of referrals or tests you are waiting for. Any time off work in the last three years. Your past health. Details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultations with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of: malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually worsening) diseases; musculoskeletal disease or injury, for example arthritis, rheumatism, back problems or any other disorder of the joints or muscles; anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose contact with reality), stress or fatigue; suicidal thoughts or attempts at suicide; or conditions related to drug or alcohol misuse or smoking or chewing tobacco products. Details of any biopsies, blood tests, electrocardiograms (heart tests), height and weight if measured in the last two years, urinalyses (tests on urine), x-rays or other investigations. Any blood pressure readings in the last three years. Any history of disease among your parents or brothers or sisters that you have told your doctor about. We have asked your doctor not to reveal information about: negative tests for HIV, Hepatitis B or C; any sexually-transmitted diseases unless there could be long-term effects on your health; or predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from. The information you and your doctor provide about your health may result in us: refusing to provide insurance; increasing premiums above standard rates; setting premiums at standard rates; or applying additional exclusions. If you have any questions about your rights under the appropriate Act or questions relating to the process of getting, assessing or storing medical information, please write to: Principal Medical Officer, Clerical Medical, 15 Dalkeith Road, Edinburgh EH16 9AS Do you require to see any medical report on yourself before it is sent to Clerical Medical? 16

18 Instruction to your bank or building society to pay by Direct Debit Please fill in the whole form using a ball point pen and send it to: Originator s Identification Number Clerical Medical, PO Box 28121, 15 Dalkeith Road, Edinburgh EH16 9AS Bank or building society branch full postal address and account details Name(s) of Account Holder(s) For Clerical Medical official use only. This is not part of the instruction to your bank or building society. Bank or building society account number Branch sort code To: The Manager Bank/Building society name Address Instruction to your bank or building society Please pay Clerical Medical Direct Debit from the account detailed on this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with Clerical Medical and, if so, details will be passed electronically to my Bank/ Building Society. Signature Postcode Clerical Medical reference number Banks and Building Societies may not accept Direct Debit Instructions for some types of account. This guarantee should be detached and retained by the payer. The Direct Debit Guarantee This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit Clerical Medical will notify you ten working days in advance of your account being debited or as otherwise agreed. If you request Clerical Medical to collect a payment, confirmation of the amount and date will be given to you at the time of the request If an error is made in the payment of your Direct Debit, by Clerical Medical or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society If you receive a refund you are not entitled to, you must pay it back when Clerical Medical asks you to You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us. Clerical Medical is a trading name of Scottish Widows Limited. Scottish Widows Limited is registered in England and Wales Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number

19 Clerical Medical is a trading name of Scottish Widows Limited. Scottish Widows Limited is registered in England and Wales Registered office in the United Kingdom at 25 Gresham Street, London EC2V 7HN. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register number EG909/0318