Flexible Mortgage Plan

Transcription

1 to alter your plan outside the Guaranteed Insurability options Existing Flexible Mortgage Plan number Guidance notes Important read this before you apply Please make sure that every question in each section of this application form is answered. Failure to do so could delay the processing of the application. The answers you provide will affect our decision to accept your application or the amount of premium you ll pay. You should answer all questions honestly and fully. We may not pay any claim, have to amend the terms of your policy or at worst cancel your policy if you: don t answer the questions honestly give us incomplete or misleading answers, or don t advise us of a change in the information you provided in response to our questions prior to the date we have agreed the terms of your cover. If we ask you to have a medical examination to help us give you a decision on your application or because your application has been selected at random as part of our quality control procedures, we will use the answers you give to the doctor, along with any information we get from other insurance companies about your medical history, to make our decision. Please read the key features and your personal illustration before completing this form. Did you receive financial advice in respect of this application to alter your plan? If you ve received advice your financial adviser will give you details of any advice charges. tes to help you complete this form Twin Plans The First Life should complete the GREEN sections A, B, C (if applicable), D and the Direct Debiting Instruction. The Second Life should complete the ORANGE sections E, F, G (if applicable), H and the Direct Debiting Instruction. Single and Joint life Plans Please complete the GREEN sections A, B, C (if applicable), D and the Direct Debiting Instruction. The Life (Lives) Assured is (are) the person(s) on whose death or critical illness the sum assured is payable. For internal use only Sales/local office no: Financial adviser no: Consultant no: Financial adviser s details Name of contact: Telephone no. Fax no: Clerical Medical

2 Please complete in CAPITAL LETTERS and give careful consideration to any declaration before signing it. SECTION A To be completed by all Lives Assured EXCEPT the Second Life on a Twin Plan (see the ORANGE sections from page 20 onwards). Part 1. Details of the Life (Lives) to be assured First Life Second Life (Joint life only) Sex male female Sex male female Mr/Mrs/Miss/Ms or other title Mr/Mrs/Miss/Ms or other title Surname Surname Full forename(s) Full forename(s) Address Address Country Postcode Country Postcode Marital status single married divorced separated widowed Marital status single married divorced separated widowed of birth Day month year of birth Day month year Country of birth Country of birth Length of residence in the UK Length of residence in the UK years months years months Nationality (list if more than one held) Nationality (list if more than one held) Country of residence (if other than UK) Country of residence (if other than UK) For tax purposes are you resident in the UK? For tax purposes are you resident in the UK? Occupation i. What is your job title? ii. Exactly what duties are carried out in your job? 1 Clerical Medical

3 First Life Second Life (Joint life only) iii. Does it involve any hazardous activities (for example, working at heights)? If, the details are: If, the details are: iv. As part of your occupation do you drive more than 18,000 miles per year (excluding travel to and from your normal place of work)? If, please state average miles per year If, please state average miles per year Hazardous pursuits Have you any intention of participating in any hazardous leisure activities (for example climbing, motor sport, diving or aviation)? If, the details are: If, the details are: Additional details of Life (Lives) Assured Please state your height and weight. Height (without shoes) Weight (in normal clothes) Height (without shoes) Weight (in normal clothes) How much alcohol do you drink? Beer 1 Pint = 2.5 units Wine 1 glass (175 ml) = 2.5 units Spirits 1 standard unit = 1.5 unit units each week units each week Have you smoked cigarettes in the last 12 months? If, what is/was your average daily consumption? If, what is/was your average daily consumption? Clerical Medical 2

4 Part 2. Plan details Term years Assumed rate of growth on investment funds Please state the assumed growth rate used in your illustration Growth rate Premium option The premium amounts will be as per your illustration for the Level, Low Start and Investment Step-Up options. Level premiums or Low Start increasing at either 10 or 20 or Investment Step-up premiums increasing at either 10 or 20 or Additional Investment If selected, total amount of basic and additional investment premium Frequency of premium payment Monthly by Direct Debit or Annually Commencement date (if known) / / Investment choice Please state the investment funds used in your illustration for premiums to be allocated to. Please give whole percentages only and the total must equal 100. For the choice of funds available, please speak to your financial adviser. We may change the selection of funds that we make available. Fund name(s) of total investment in each fund 3 Clerical Medical

5 PLAN OPTIONS (NON-TWIN PLAN CASES) Basic sum assured Amount of basic sum assured (This is the minimum amount payable to the assured at maturity (or on acceptance of a critical illness claim if Critical Illness Cover has been selected), or his/her dependants on the death of the life assured.) Additional sum assured Amount of additional life cover (This is the amount of life cover in addition to the basic sum assured above. The maximum additional life assured is 100 of the basic sum assured.) Please note: Total sum assured equals basic sum assured plus any additional sum assured. Critical Illness Cover (If selected, total Critical Illness Cover must at least equal the total sum assured) Do you require basic Critical Illness Cover? (If selected this will equal the basic sum assured) Do you require Additional Critical Illness Cover? Amount of Additional Critical Illness Cover Waiver of Premium please specify the deferred period Do you require Waiver of Premium? Second Life First Life (Joint life only) Deferred period Additional Waiver of Premium Option (This is an extension to the Waiver of Premium option to provide payments towards existing premiums paid on any existing plans associated with the same mortgage (not limited to your Flexible Mortgage Plan). This is available on the same eligibility and payment terms and conditions specified for your Flexible Mortgage Plan Waiver of Premium.) Do you require Additional Waiver of Premium? Amount of Additional Waiver of Premium (maximum of 100 of basic Flexible Mortgage Plan premium) PLAN OPTIONS FOR TWIN PLAN CASES (FIRST LIFE ONLY) Basic sum assured Amount of basic sum assured (This is the minimum amount payable to the assured at maturity (or on acceptance of a critical illness claim if Critical Illness Cover has been selected), or his/her dependants on the death of the life assured.) Total sum assured (The total sum assured should equal the total loan amount of the property being purchased) 3 6 months months per month Critical Illness Cover Do you require Critical Illness Cover? (If selected this will equal the total sum assured) Waiver of Premium Do you require Waiver of Premium? Deferred period Do you require Additional Waiver of Premium? (This is an extension to the Waiver of Premium option to provide payments towards existing premiums paid on any existing plans associated with the same mortgage (not limited to your Flexible Mortgage Plan). This is available on the same eligibility and payment terms and conditions specified for your Flexible Mortgage Plan Waiver of Premium.) Amount of Additional Waiver of Premium (Maximum of 100 of basic Flexible Mortgage Plan premium) 3 6 months months per month Please note: Any Additional Waiver of Premium cover will apply to the same lives and on the same terms as basic Waiver of Premium. It is only available if basic Waiver of Premium has been chosen. Clerical Medical 4

6 Part 3. Mortgage details Total loan amount Term years months Purpose of mortgage purchasing a main residence switch from capital and interest (within 3 months of the plan being effected) to endowment method of repayment home improvement loan other (please give details overleaf) re-mortgage Please give details of the purpose of the mortgage if all of the categories previously shown do not apply Address of property being mortgaged Name and address of lender Postcode Upon commencement of this policy, all correspondence will be sent to the mortgage address. Are there any other life assurance policies being used in connection with this mortgage by yourself or any other parties? If, please complete the details below. Details of first policy Details of second policy Postcode Full name(s) of applicant Full name(s) of applicant Sex male female Sex male female Full name(s) of second applicant, if applicable Full name(s) of second applicant, if applicable Sex male female Sex male female Total sum assured Total sum assured If you have any additional policies, please continue on a separate sheet of paper. 5 Clerical Medical

7 Part 4. Doctor Please give the name and address of your current doctor. First Life Second Life (Joint life only) Name Dr Name Dr Address Address Postcode Postcode Please note: Although Clerical Medical reserves the right to seek information on health matters from your doctor, it may not necessarily do so and you are therefore advised most strongly to consider carefully the following questions as Clerical Medical will be relying on your answers in considering the application. Part 5. Life existing proposal details Has any proposal for life, Critical Illness, accident or health insurance on your life ever been declined, deferred or offered on non-standard terms? First Life Second Life (Joint life only) If, the details are: If, the details are: Names of insurance companies Names of insurance companies s s SECTION B SIMPLIFIED APPLICATION SCHEME Complete this section only if you are aged 54 or under. If you are aged 55 or over please go straight to Section C Health and other information. If you require Critical Illness Cover and are aged 50 or over, please go straight to Section C. Important notes The Simplified Scheme minimises the medical information required for eligible applicants. In a joint life case, each life is assessed on its own merits. Therefore, it is possible for one life to be eligible for the Simplified Scheme while the other life is not. The directive notes at the end of each of the following sections apply on an individual basis. Providing you complete the questions accurately, and are not required to complete the further sections of this form which relate to health, Clerical Medical will normally offer terms without further medical evidence. If, after acceptance of this application, it becomes apparent that any of the questions should have been answered, you must inform Clerical Medical; you may be asked to complete a new application, and any contract arising out of such acceptance may be rendered void. Clerical Medical 6

8 Part 1. Eligibility a. Does the total sum assured or the total Critical Illness Cover provided under this plan, together with any other policies previously effected with Clerical Medical under a Simplified Scheme, exceed First Life Second Life (Joint life only) 125,000 if you are aged 49 or under, or 30,000 if you are aged inclusive? b. Does the total sum assured or the total Critical Illness Cover provided under this plan exceed the amount of the total loan by more than 10? c. Will the plan be used for any purpose other than repayment of a loan on your main residence (including home improvements/ remortgage) which is to be effected within three months of the date of the plan? (If this is a Twin Plan application or a single plan on two lives, both lives must be parties to the mortgage.) d. Will the plan mature any later than your 70th birthday? If you have answered to all of the above questions, please complete Part 2 Health questions. If you have answered to one or more of the above questions, you are not eligible for the Simplified Scheme. Please go to Section C. Part 2. Health questions a. Have you attended or been advised to attend your doctor s surgery, any hospital or clinic for any form of advice, operation, treatment or test within the last 12 months OR are you subject to regular reviews or receiving any medical treatment or attention? (Colds, influenza, minor injury and routine pregnancy consultations may be excluded.) First Life Second Life (Joint life only) b. i. Do you have or have you ever had a positive test for HIV or Hepatitis B or C? ii. In the last 5 years have you tested positive or been treated for any disease which was transmitted sexually? c. Is any mental or physical illness or injury preventing you from working full time now, or has it done so for any period of two weeks or more during the last five years? 7 Clerical Medical

9 Please only answer the following questions if you require Critical Illness Cover. d. Have you ever suffered from heart disease, stroke, cancer, diabetes, kidney disease, multiple sclerosis or any other disabling condition? First Life Second Life (Joint life only) e. Have any 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 disease? If you have answered to all of these questions, you are eligible for the Simplified Scheme, please go to Section D. If you have answered to one or more of the above questions, you are not eligible for the Simplified Scheme, please go to Section C. SECTION C HEALTH AND OTHER INFORMATION This section should be completed if you are not eligible for any one of Parts 1 and 2 in Section B. Life Cover, Waiver of Premium and Critical Illness Cover Please answer the following questions, stating or by the appropriate box and giving full details and any relevant dates, continuing on a separate sheet of paper if necessary. First Life Second Life (Joint life only) 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: Result Result 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: Result Result Clerical Medical 8

10 First Life Second Life (Joint life only) 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 Result Result 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: Result Result ii. diabetes? If, the details are: If, the details are: iii. any form of lump (benign or malignant), cancer, growth or other malignancy? If, the details are: If, the details are: 9 Clerical Medical

11 First Life Second Life (Joint life only) iv. kidney, bladder, urinary, stomach, intestinal or liver disorder? If, the details are: If, the details are: 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: Clerical Medical 10

12 First Life Second Life (Joint life only) 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 any 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 disease? If, the details are: If, the details are: Age at time Relationship Age at time Relationship f. i. Do you have or have you ever had a positive test for HIV or Hepatitis B or C? If, the details are: If, the details are: ii Within the last five years have you been tested positive or been treated for any disease which was transmitted sexually? If, the details are: If, the details are: 11 Clerical Medical

13 First Life Second Life (Joint life only) g. Have you ever injected non-prescription drugs? If, the details are: If, the details are: h. Have you ever taken any drugs other than for medicinal purposes? If, the details are: If, the details are: i. 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 Clerical Medical 12

14 SECTION D Important tes You or your refers to the Life/Lives to be Assured. We or us refers to Clerical Medical. Please read these notes carefully. If you do not understand any of them, please let us know. We will rely on them so it is important that you understand them. 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. 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 creditworthiness and product suitability, check your identity, manage your account, trace and recover debts and prevent criminal activity. 13 Clerical Medical

15 SECTION D (continued) 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. Second Life First Life (Joint life only) Post Device tifications 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. Money Laundering Regulations We may need to verify your identity to comply with current regulations and to help identify and prevent fraud. We ll use a credit reference agency to do this (this is not to check your credit worthiness). They use a range of databases (including the Electoral Register) to verify your name, date of birth and address. We then use a scoring method to authenticate your identity. If this search does not verify your identity, we may ask you to give us some documents to do this instead. The search isn t used to assess insurance risks. If you want to know which credit reference agency we use, please ask us. We may share this information with other organisations involved in the prevention of money laundering, fraud and other financial crime. Clerical Medical 14

16 SECTION D (continued) Genetic Testing It is important that you read this section if you have ever had a genetic test. We comply with the Association of British Insurers policy on genetics and insurance. We ll never ask you to take a genetic test. You don t have to tell us about any genetic test result you ve had if: (i) you re applying for Life Cover and the total amount of that benefit, added to any existing life insurance policies you have, is less than 500,000; (ii) you re applying for Critical Illness Cover and the total amount of that benefit, added to any existing critical illness policies you have, is less than 300,000; You may need to tell us if your benefit amount goes over these limits. The Government s Genetics and Insurance Committee has agreed that certain genetic test results can be used for insurance and we will only use these ones. Please ask us if you think this may apply to you or go to However, you must always tell us about any genetically inherited condition which your family has a history of, or which you have symptoms of or are being treated for. If you want, you can tell us about any negative genetic test results to show you have not inherited a genetic disorder and we ll take this into account. Medical Examinations Random Sampling Please be aware that we may request a medical examination within 30 days after the start date of your policy. This forms part of our quality control procedures and individual cases accepted without medical evidence are selected at random. An examination might include a simple test (e.g. saliva or urine test) to confirm that you are a non-smoker. If you don t give us this information or if the examination highlights information that we asked for which you have knowingly failed to disclose, we can amend the terms of your policy or at worst cancel your policy. Medical Reports 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 Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (rthern Ireland) Order 1991, whichever is appropriate. You do not need to give your permission but, if you don t, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance. By signing the Declaration, you give us agreement that we can ask for a report if required. You can ask to see the report before the doctor sends 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 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. 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. After six months, if your doctor no longer has the report, you can ask us for a copy and we will send it on to your doctor. 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. Your doctor will not be asked to tell us about negative HIV or Hepatitis B or C tests, any sexually transmitted diseases (unless they could result in long-terms effects on your health) or predictive genetic tests (unless they demonstrate that you have not inherited a condition which your family has suffered from). The information you and your doctor give us about your health may mean we refuse your application, you have to pay extra for your insurance, we apply additional exclusions or we accept you at standard rates. If you die, we might have to approach your estate for consent to access your medical records. If consent is not granted then we might not pay out on your policy. Your answers to our questions You should answer all questions we gave asked in this application honestly and fully. The answers you provide will affect our decision to accept your application or the amount of premium you will pay. We may not pay any claim, have to amend the terms of your policy or at worst cancel your policy if you: don t answer the questions honestly give us incomplete or misleading answers, or don t advise us of a change in the information you provided in response to our questions prior to the date we have agreed the terms of your cover. 15 Clerical Medical

17 SECTION D (continued) Declaration You have read the Important tes, consisting of: Data Privacy tice Money Laundering Regulations Genetic Testing Medical Examinations Medical Reports Your answers to our questions You declare that, to the best of your knowledge and belief, the information given in this application is true and complete. If any of the information or the answers provided are subsequently found to be incorrect or incomplete then you understand Clerical Medical may amend the terms of your policy or at worst cancel your policy. You agree to us asking any doctor you have consulted about your physical or mental health to provide medical information so we may assess the application. You agree that we may gather relevant information from other insurers about any other applications you have made to them. You authorise people whom we ask to provide medical information to do so. You agree that we may gather medical records within six months of the start of the policy(ies), or to verify any claim made on the policy(ies). You agree that the details you have provided, including health information and any further medical information obtained as authorised by you, shall be used for the purposes already described. You confirm that you have checked the answers to your health and lifestyle questions and that, to the best of your knowledge, the answers you have given are true and complete. You understand that if you have made an incorrect or misleading statement a claim may be refused and we may amend the terms of your policy or at worst cancel your policy. You need to let us know if an answer to a question in the application changes before the date we have agreed the terms for the cover. If you don t do this, we may not pay any claim, have to amend the terms of your policy or at worst cancel your policy. We will have agreed the terms once we have your signed confirmation that all your application answers are true and complete and we have written to you after that confirming our terms. You understand that you will not be able to claim under the policy until the policy start date and that the policy cannot be backdated to a start date which is on or before the date of any event which might lead to a claim. You agree that this application together with any statements made to a medical examiner, makes up the contract between you and us. You understand that we will rely on the answers you have given and we will not necessarily ask your doctor for information about your medical history to offer terms for this application. You understand that you may not be covered if we find that you have not made sure the answers in your application for this policy are true, complete and not misleading. You understand that you may not be covered if you do not undergo any medical examinations within 30 days of a request being made. By agreeing to this Declaration you are allowing us to process this application using the information that you have given. We may also use this information to process any claim made on the policy(ies). Life to be assured (1) Life to be assured (2) Do you want to see any medical report on yourself before it is sent to us? Lloyds Banking Group companies may use your information to contact you about products and services that may be of interest to you. If you do not wish to receive this information please tick the appropriate box. Please note that if you do not wish to receive this information, we won t be able to tell you about additional offers which we make available from time to time Signature of Life to be Assured (1): Signature of Life to be Assured (2): / / / / Clerical Medical 16

18

19 Direct Debits Instruction to your bank or building society to pay Direct Debits Please complete the whole of this form and send it to: Clerical Medical, PO Box 28121, 15 Dalkeith Road, Edinburgh EH16 9AS Bank or building society branch full postal address and account details Originator s Identification Number To: The Manager Bank/Building society Name(s) of account holder(s) Bank/Building society address Branch sort code Post code Bank or building society account number Instruction to your bank or building society Please pay Clerical Medical Direct Debits from the account detailed on this instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that the instruction may remain with Clerical Medical and, if so, details will be passed electronically to my bank/building society. Signature(s) D D M M Y Y Y Y / / Clerical Medical reference number For Clerical Medical official use only. This is not part of the instruction to your bank or building society. Banks and building societies may not accept Direct Debit instructions for some types of account. M343/0318 Please detach this guarantee and keep it for your future reference. 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, 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

20

21 Second Life (Twin Plan only) Please complete in CAPITAL LETTERS and give careful consideration to any declaration before signing it. SECTION E TWIN PLAN Second Life only. Part 1. Details of the Life to be assured Sex male female iii. Does it involve any hazardous activities (for example, working at heights? Mr/Mrs/Miss/Ms or other title Surname If, the details are: Full forename(s) Address iv. As part of your occupation do you drive more than 18,000 miles per year (excluding travel to and from your normal place of work)? Country Postcode If, please state average miles per year Marital status single married divorced separated widowed of birth Day month year Hazardous pursuits Have you any intention of participating in any hazardous leisure activities (for example climbing, motor sport, diving or aviation)? Country of birth If, the details are: Length of residence in the UK years months Additional details of Life (Lives) Assured Nationality (list if more than one held) Country of residence (if other than UK) For tax purposes are you resident in the UK? Occupation i. What is your job title? Please state your height and weight. Height (without shoes) Weight (in normal clothes) How much alcohol do you drink? Beer Wine 1 Pint = 2.5 units 1 glass (175 ml) = 2.5 units Spirits 1 standard unit = 1.5 unit units each week ii. Exactly what duties are carried out in your job? Have you smoked cigarettes in the last 12 months? If, what is/was your average daily consumption? Clerical Medical 20

22 Second Life (Twin Plan only) Part 2. Plan details Term years* Assumed rate of growth on investment funds Please state the assumed growth rate used in your illustration * Please note this must be the same as the First Life Growth rate * Premium option The premium amounts will be as per your illustration for the Level, Low Start and Investment Step-Up options. Level premiums or Low Start increasing at either 10 or 20 or Investment Step-up premiums increasing at either 10 or 20 or Additional Investment If selected, total amount of basic and additional investment premium Frequency of premium payment Monthly by Direct Debit or Annually Commencement date (if known) Please note this must be the same as the First Life Investment choice Please state the investment funds used in your illustration for premiums to be allocated to. Please give whole percentages only and the total must equal 100. For the choice of funds available, please speak to your financial adviser. We may change the selection of funds that we make available. Fund name(s) / / of total investment in each fund 21 Clerical Medical

23 Second Life (Twin Plan only) PLAN OPTIONS FOR TWIN PLAN CASES (SECOND LIFE ONLY) Basic sum assured Amount of basic sum assured (This is the minimum amount payable to the assured at maturity (or on acceptance of a critical illness claim if Critical Illness Cover has been selected), or his/her dependants on the death of the life assured.) Total sum assured (The total sum assured should equal the total loan amount of the property being purchased) Critical Illness Cover Do you require Critical Illness Cover? (If selected this will equal the total sum assured) Waiver of Premium Do you require Waiver of Premium? Deferred period 3 6 months months Do you require Additional Waiver of Premium? (This is an extension to the Waiver of Premium option to provide payments towards existing premiums paid on any existing plans associated with the same mortgage (not limited to your Flexible Mortgage Plan). This is available on the same eligibility and payment terms and conditions specified for your Flexible Mortgage Plan Waiver of Premium.) Amount of Additional Waiver of Premium (Maximum of 100 of basic Flexible Mortgage Plan premium) per month Please note: Any Additional Waiver of Premium cover will apply on the same terms as basic Waiver of Premium. It is only available if basic Waiver of Premium has been chosen. Part 3. Mortgage details Total loan amount Term years months Purpose of mortgage purchasing a main residence re-mortgage (within 3 months of the plan being effected) home improvement loan switch from capital and interest to endowment method of repayment Other please give details Address of property being mortgaged Name and address of lender Postcode Upon commencement of this policy, all correspondence will be sent to the mortgage address. Postcode Clerical Medical 22

24 Second Life (Twin Plan only) Are there any other life assurance policies being used in connection with this mortgage by yourself or any other parties? If, please complete the details below. Details of first policy Details of second policy Full name(s) of applicant Full name(s) of applicant Sex male female Sex male female Full name(s) of second applicant, if applicable Full name(s) of second applicant, if applicable Sex male female Sex male female Total sum assured Total sum assured If you have any additional policies, please continue on a separate sheet of paper. Part 4. Doctor Please give the name and address of your current doctor. Name Dr Address Postcode Please note: Although Clerical Medical reserves the right to seek information on health matters from your doctor, it may not necessarily do so and you are therefore advised most strongly to consider carefully the following questions as Clerical Medical will be relying on your answers in considering the application. Part 5. Life existing proposal details Has any proposal for life, Critical Illness, accident or health insurance on your life ever been declined, deferred or offered on non-standard terms? If, the details are: Names of insurance companies s 23 Clerical Medical

25 Second Life (Twin Plan only) SECTION F SIMPLIFIED APPLICATION SCHEME Complete this section only if you are aged 54 or under. If you are aged 55 or over please go to Section G Health and other information. If you require Critical Illness Cover and are aged 50 or over, please go to Section G. Important notes The Simplified Scheme minimises the medical information required for eligible applicants. Providing you complete the questions accurately, and are not required to complete the further sections of this form which relate to health, Clerical Medical will normally offer terms without further medical evidence. If, after acceptance of this application, it becomes apparent that any of the questions should have been answered, you must inform Clerical Medical; you may be asked to complete a new application, and any contract arising out of such acceptance may be rendered void. Part 1. Eligibility a. Does the total sum assured or the total Critical Illness Cover provided under this plan, together with any other policies previously effected with Clerical Medical under a Simplified Scheme, exceed 125,000 if you are aged 49 or under, or 30,000 if you are aged inclusive? b. Does the total sum assured or the total Critical Illness Cover provided under this plan exceed the amount of the total loan by more than 10? c. Will the plan be used for any purpose other than repayment of a loan on your main residence (including home improvements/remortgage) which is to be effected within three months of the date of the plan? (As this is a Twin Plan application, both lives must be parties to the mortgage.) d. Will the plan mature any later than your 70th birthday? If you have answered to all of the above questions, please complete Part 2 Health questions. If you have answered to one or more of the above questions, you are not eligible for the Simplified Scheme. Please turn to Section G. Part 2. Health questions a. Have you attended or been advised to attend your doctor s surgery, any hospital or clinic for any form of advice, operation, treatment or test within the last 12 months OR are you subject to regular reviews or receiving any medical treatment or attention? (Colds, influenza, minor injury and routine pregnancy consultations may be excluded.) b. i. Do you have or have you ever had a positive test for HIV or Hepatitis B or C? ii. In the last 5 years have you tested positive or been treated for any disease which was transmitted sexually? c. Is any mental or physical illness or injury preventing you from working full time now, or has it done so for any period of two weeks or more during the last five years? Clerical Medical 24

26 Second Life (Twin Plan only) Please only answer the following questions if you require Critical Illness Cover. d. Have you ever suffered from heart disease, stroke, cancer, diabetes, kidney disease, multiple sclerosis or any other disabling condition? e. Have any 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 disease? If you have answered to all of these questions, you are eligible for the Simplified Scheme, please go to Section H. If you have answered to one or more of the above questions, then you are not eligible for the Simplified Scheme, please complete Section G. SECTION G HEALTH AND OTHER INFORMATION This section should be completed if you are not eligible for any one of Parts 1 and 2 in Section F. Life Cover, Waiver of Premium and Critical Illness Cover Please answer the following questions, stating or by 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? c. Have you ever undergone or been recommended to undergo hospitalisation, an operation, x-ray or any other investigation? If, the details are: Type If, the details are: Reason Result Result 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? 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: Result Result 25 Clerical Medical

27 Second Life (Twin Plan only) ii. diabetes? 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: iii. any form of lump (benign or malignant) cancer, growth or other malignancy? If, the details are: viii. multiple sclerosis, tremor, numbness or double vision, or any form of paralysis? If, the details are: iv. kidney, bladder, urinary, stomach, intestinal or liver disorder? ix. any form of eye or ear disorder? If, the details are: If, the details are: v. asthma, bronchitis or any respiratory disorder? x. any disorder of the brain? If, the details are: If, the details are: vi. anxiety, depression or any psychiatric or nervous disorder? If, the details are: Clerical Medical 26

28 Second Life (Twin Plan only) e. Have any of your near relatives (ie parents, brothers or sisters) died or suffered from any of the following before age 65: g. Have you ever injected non-prescription drugs? 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 disease? If, the details are: If, the details are: h. Have you ever taken any drugs other than for medicinal purposes? Age at time Relationship If, the details are: f. i. Do you have or have you ever had a positive test for HIV or Hepatitis B or C?. If, the details are: i. 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: ii. Within the last five years have you tested positive or been treated for any disease, which was transmitted sexually? Country If, the details are: 27 Clerical Medical

29 Second Life (Twin Plan only) SECTION H Important tes You or your refers to the Life/Lives to be Assured. We or us refers to Clerical Medical. Please read these notes carefully. If you do not understand any of them, please let us know. We will rely on them so it is important that you understand them. 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. 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 creditworthiness and product suitability, check your identity, manage your account, trace and recover debts and prevent criminal activity. Clerical Medical 28