Group Protection Benefits from Aviva - Application Form

Transcription

1 Group Protection Benefits from Aviva - Application Form to Friends First Life Assurance Company dac (part of the Aviva Group) References to Aviva contained in this form apply to Friends First Life Assurance Company dac, the company in the Aviva Group that underwrites the insurance cover for which you are applying. This form is a legal document and together with the policy conditions (a copy of which has been made available) and policy schedule forms part of any subsequent contract if Aviva accept your application. All sections must be fully completed and any alterations initialled by the signatory/signatories. A copy of the completed application form is available on written request. The information in the application form must be true and complete in all material respects and we must be given all relevant information in relation to your taking out this policy with us and in relation to calculation of premiums at the start of the policy and at each anniversary date. However, in accordance with the Disability Act 2005, you should not tell us the results of genetic tests. Any changes between completing the application form or giving us information and the start date or renewal date of the policy must be disclosed to us. Information is material or relevant if it might influence the judgment of a reputable insurer when fixing the premiums or cover amount or when deciding whether to provide cover at all. Material facts could include medical history, smoking history and details of occupation, travel and pastimes (but not genetic tests). If you are in any doubt as to whether certain facts are material, you should tell us about them anyway. You must also tell us about any changes to the information you give us up until your policy starts. If you do not tell us about material facts when you apply for cover, when you update information to us for each anniversary date (and at such other times as may be required) or at the claims stage, this might mean that your contract could be cancelled without premiums being returned, we don t pay a claim and you may encounter difficulty trying to purchase insurance elsewhere. The Employer in the case of Group Income Protection and the Trustee in the case of Group Life must be resident for tax purposes in the Republic of Ireland. If this is not the case this might mean that your contract could be cancelled without premiums being returned and/or a claim not being paid. You must inform Aviva of any change in your country of residence during the lifetime of the policy. Please complete every section and where relevant tick the appropriate box. If a section does not apply, write n/a and please use capital letters throughout. SECTION 1 YOUR DETAILS Name of plan Registered employer name Address of Registered Office Business Address Employer Tax Number If any person you have included in this plan is not employed directly by you, please give us the following information. Registered employer name Does your business trade under another name Address of Registered Office How are they associated to you (If there is more than one other employer, please give details on a separate sheet.) SECTION 2 CHOOSING YOUR PLANS Please choose the benefits you are applying for by ticking the appropriate box or boxes below and please answer the questions which apply to each plan. Yes No Yes No Group Life Assurance Income Protection Spouse s Pension Death-in-Service Is this a new to market plan or an existing plan? New If existing please provide copy of previous acceptance terms & benefits. Date the cover will start Existing Renewal date Premiums will be paid Monthly Yearly

2 SECTION 3 MEMBERSHIP (ELIGIBILITY) A Name of category (category 1) Minimum age at joining Maximum age at joining Service required before joining Does membership begin Immediately? At the next renewal date? Name of category (category 2)(if applicable) Minimum age at joining Maximum age at joining Service required before joining Does membership begin Immediately? At the next renewal date? If further categories apply please complete details on a separate sheet. B Definition of salary: Basic salary (excluding all variable elements) If other, please specify: (bonus, commission, etc.) Do increases in sum insured linked to salary apply Immediately? At the next renewal date? Are all eligible employees living in Ireland for tax purposes Yes No Please confirm that all eligible employees have been included in your final data Yes No SECTION 4 BENEFIT DETAILS Group Life Insurance (structure of benefit e.g. 4 x salary) Benefit category 1 Benefit category 2 When will this cover end? (e.g. 65 years) other Continuation option Yes No Spouse s Pension Death-in-Service (structure of benefit e.g.: 66.67% x salary) Benefit category 1 Benefit category 2 Rate of the increase while the benefit is being paid None 3% a year 5% a year CPI (Max 3%) CPI (Max 5%) Children s Pension Death-in-Service (structure of benefit e.g.: 66.67% x salary) Benefit category 1 Benefit category 2 Rate of the increase while the benefit is being paid None 3% a year 5% a year CPI (Max 3%) CPI (Max 5%) Income Protection (structure of benefit e.g. 75% x salary less once Social Welfare Benefit) Benefit category 1 Benefit category 2 Premium Protection Benefit (structure of benefit e.g.: 10% x salary) Benefit category 1 Benefit category 2 Income Protection & Premium Protection Benefit Details When will this cover end? (e.g. 65 years) SRA** other What is the deferred period? 13 weeks 26 weeks 52 weeks Rate of the increase while the benefit is being paid* None 3% a year 5% a year Continuation option Yes No CPI (Max 3%) CPI (Max 5%) * Escalation of a claim in payment may be restricted to conform to maximum benefit rules. Please send us, with this application form, a list of the proposed members and a description of their exact occupations. ** State Retirement Age

3 SECTION 5 DECLARATION OF TRUST DETAILS (Fill in this section only if you have chosen Group Life Assurance and/or Spouse s Death-in-Service Benefits) Please state under which trust the benefits in this proposal are to be covered a. Under an existing trust If the benefits shown in this form are to be provided under an existing plan you have set up, we require all of the following information, together with a copy of the Revenue Commissioners letter of formal approval and a copy of the existing trust deed. Please note that Aviva takes no responsibility in respect of the documentation services for the scheme in this case. Title of trust Revenue reference number Pensions Authority registration number b. Under a new trust If the benefits shown in this form are to be provided by setting up a new separate trust. Will the new trust be prepared by: Aviva or by someone else? and the employer is a limited company and the employer is also to be the appointed trustee, please complete the Declaration of Trust, you should complete the standard Aviva Declaration of Trust, which can be provided to you under separate cover. Should any other scenario apply (i.e. individual trustees are to be appointed, the employer is a partnership etc.) please contact your broker / Aviva representative who will arrange for an appropriate trust to be issued for signature. SECTION 6 DECLARATION OF ATTENDANCE Please tick if all the members are actively at work** on the risk date **Actively at work means that the employee: A. Is working their normal contracted number of hours. B. Has not received medical advice to refrain from work. C. Is not restricted from fully performing the normal duties associated with their occupation. Note: those on paid and unpaid statutory leave (maternity, Parental and carer) can be considered actively at work so long as they would be able to fulfil points B and c above. If not, please list all the members who could not actively work because of illness or injury on the cover start date shown earlier. Name Name Name Date illness began Date illness began Date illness began DD MM YY DD MM YY DD MM YY If you are providing an Income Protection Plan please list the members who were away from work because of illness or injury for more than 10 working days in the three calendar months immediately before the cover starts. Name Name Name Number of days absent Number of days absent Number of days absent If you want to list more than 3 members, please specify additional information. If the above information differs to what was provided at the quotation stage, Friends First Life Assurance Company dac reserve the right to alter the quote or decline claims. If Risk Benefits were previously insured, please provide details of the last underwriting terms issued and provide the name of the previous insurer.

4 SECTION 7 Group Life Data Protection Notice Data Protection Notice Group Life Insurance Underwritten by Friends First Life Assurance Company dac (part of the Aviva Group) Please read this Data Protection Notice carefully before you complete the Declarations 1. Introduction We collect and use personal information about individuals so that we can provide insurance and pension products requested by our customers. This Data Protection Notice explains the most important aspects of how we use personal information and what rights individuals have. You can get more information about the terms we use and view our Privacy Policy at or request a copy by writing to the Data Protection Officer, Aviva, One Park Place, Hatch Street, Dublin 2 or call us on (01) This Data Protection Notice applies mainly to the lives to be insured whose information is relevant to the insurance under the policy and the administration of the Scheme of which the lives insured are members. This Data Protection Notice also applies (as regards the more limited information that will hold in respect of them (e.g. as regards their contact details) to: signatories to the application for the policy the directors of corporate trustee/employer of the Scheme individual trustees of the Scheme the employer if a sole trader or a partnership. The terms you and your are used accordingly in this Data Protection Notice. The data controller responsible for processing this personal information is Friends First Life Assurance Company dac ( we us our ) as the insurer of the of the policy (issued to the trustees of the Scheme as Policy Owners). Additional data controllers involved in policy and the Scheme include: trustees of the Scheme employer of the Scheme intermediary/financial broker (who is responsible for the sale and suitability of the product). Risk assessment for Group Protection will be carried out on anonymised basis (i.e. without identifying personal information of the lives insured) where appropriate. We mainly process personal information of the lives insured: if individual risk assessment/underwriting applies (e.g. because cover amount exceeds our free cover limit) where a benefit is claimed under the policy administering benefits. 2. Type of Information/Where Collected We collect personal information (including name, age/dob, salary, PPSN, employment history, pensions history) from you and any relevant third parties (including that authorised by the Declarations) under and in relation to the application for the policy and the administration of the policy and the Scheme, to include processing claims and complaints. We may need to ask for health data relevant to the policy. We recognise that information about health is particularly sensitive information. We will only collect and use such information where we need to and where it is proportionate for the purposes of the policy of insurance. Health data includes (with the exception of the results of genetic tests) lives to be insured health data to include, existing or previous health conditions, medical history and lifestyle (e.g. smoking habits/history) and family health history. If you are asked to provide health data, please do not send us the results of any genetic tests carried out on you or any other relevant person. You don t have to provide us with any personal information, but if you don t provide the information we need we may not be able to proceed with the application, cover for a life or lives to be insured or claim for benefit. We will let you know what information is required to proceed with your application or any claim you make. We may also use personal information about people other than you e.g. where individual underwriting applies family health history of the lives insured, (if benefits payable to them) spouse/dependants of members the Scheme. If you are providing personal information about another person we require you to let them know what information you ve shared with us, share with them this Data Protection Notice and obtain their confirmation that they have read and understand this Data Protection Notice. If you or they have any queries or concerns please contact us in one of the ways described below. We may also collect personal information: already held about you within the Aviva Group (identified in Privacy Policy), including details from previous, policies of insurance and claims;

5 from your intermediary, financial broker or other nominated representative; from parties relevant to claim process (e.g. claimant, private investigators engaged by us, witnesses, solicitors and independent experts); from publicly available information including social media websites and online content, newspaper articles, tv, radio and other media content, court judgements, public registers and specialist databases (for example Companies Registration Office, Vision-net, Oracle, Dow Jones, SoloCheck), and (only for purposes of verifying your identity) electoral register; from other insurance companies, trustees of other pension schemes, previous employers, other pension providers. 3. Legal Basis and Purposes for Use The legal basis we rely on to process your personal information and the purposes for which we collect and use personal information are summarised below. Further information is set out in our Privacy Policy. (a) Personal Information (other than health data) Legal Basis for Use In order to take steps prior to entering into a contract i.e. the insurance policy For the performance of a contract i.e. the insurance policy and administration of Scheme For compliance with a legal obligation Legitimate Interests (of us and/or the Policy Owners and/or the lives insured/ members To protect your vital interests: Legitimate Interests (of us) Legitimate Interests (of us) Purposes for Use To consider whether (and if so on what terms) to accept the application for the policy to include: assessing the lives to be insured for underwriting/risk purposes (e.g. where outside free cover limits or other group protection parameters, determining what premiums will apply, protection against non-disclosure of material facts and preventing or detecting fraud having regard to the related administrative and regulatory requirements e.g. Revenue approval of the Scheme. To administer the policy for the Policy Owners in accordance with the policy conditions (a copy of which are available on request from us or intermediary/financial broker), including to: evaluate, validate and process any claims and complaints and the prevention and detection of fraud in respect of the policy support the administration of the Scheme e.g. arrange Revenue approval of the Scheme address Pension Act requirements e.g. disclosure other statutory requirements e.g. pension adjustment orders. Compliance by us with all relevant legal and regulatory obligations We may process personal information of people other than the Policy Owners, in order to: consider the application for the policy and related administrative and regulatory requirements administer the policy and support the administration of the Scheme. This processing will also be in the legitimate interests of the Policy Owners in the conduct of their business and/or the lives insured/members of the Scheme in having access to and the benefit of the Scheme. This will only arise in exceptional circumstances where we may use and/or disclose information to protect the members of the Scheme e.g. liaise with the Pensions Authority and/or Revenue Commissioners if trustee/employer in liquidation To support the legitimate interest that we have as a business in assessing our reinsurance requirements and managing arrangements we have with reinsurers (these arrangements are necessary for risk transfer by insurers); managing our legal affairs including exercising our legal rights and defending claims; and managing our business effectively e.g. with third party service suppliers. To support other legitimate interests that we have as a business and that the insurance industry at large has to manage security including preventing, detecting, investigating and/or protecting our customers and ourselves from theft and fraud. We may use your personal information to make searches of our records, if you give us false personal information or fail to disclose personal information during the application or claims process and we suspect fraud we will record this.

6 Legitimate Interests (of Aviva) To carry out other activities that are in the public interest Our legitimate interests to better understand our customers and improve service enhancement and business performance, this includes customer analytics; market research; processing management information; reporting (including Aviva Group reporting) for compliance, audit, statistical or research purposes; staff training; providing online services; and in the event of any portfolio transfer, merger, acquisition, disposal or other such transaction relating to our business. Where practical we will anonymise the data we analyse. We may need to use personal information to verify your identity and carry out anti-money laundering checks. Your Right to Object Please note that you have a right to object to processing of your personal information where that processing is carried out on the grounds of legitimate interests or public interest. If you do object: we will have an opportunity to demonstrate that there are compelling legitimate grounds which override your rights and freedoms or that processing is necessary for the establishment, exercise or defence of legal claims a successful objection may have consequences for our continued administration of the policy (e.g. prevent us assessing future claims and/or the policy may be cancelled) and we can discuss these if you want to object. (b) Health Data Health data is used for the purposes of set-up and underwriting of policy of insurance, administering policy (e.g. processing claims, handling complaints), reinsurance or fraud investigation in relation to the policy. The legal basis on which we process health data in respect of the lives to be insured is that: Irish Data Protection law allows us where necessary and proportionate to use heath data for the purposes of a policy of insurance; and/or processing is necessary for the establishment, exercise or defence of legal claims. Where we process health data for the purpose of a policy of insurance we will take suitable and specific measures to safeguard the fundamental rights and freedoms of individuals. Further information can be found in our Privacy Policy. 4. Who we share your information with Where relevant, we may share personal information with: (1) Other Aviva Group companies, agents, professional advisers acting for us (e.g. medical practitioners, lawyers, private investigators) and third party service providers. (2) The intermediary/financial broker and at its request, third party service providers who provide services to the intermediary/financial broker. (3) Your agents and other third parties relevant to you and/or the policy, including doctors and other relevant medical practitioners, employer, previous employers, other insurance companies, trustees, administrators and other pension providers. (4) If appropriate with regard to relevant legal/tax regulatory obligations and Revenue approval of the Scheme: with regulatory bodies, law enforcement bodies, government departments including UK Financial Conduct Authority, UK Prudential Regulatory Authority, Central Bank of Ireland, Financial Services and Pensions Ombudsman, Pensions Authority, Revenue Commissioners/Inspector of Taxes, Gardaí, Criminal Assets Bureau, Data Protection Commission and Department of Social Protection. (5) With other insurers and financial services companies, public bodies, (either directly or using shared databases) and industry bodies such as Insurance Ireland. (6) With reinsurers who provide reinsurance services to us and for each other. Reinsurers will use your data to decide whether to provide reinsurance cover, assess and deal with reinsurance claims and to meet legal obligations. They will keep your data for the period necessary for these purposes and may need to disclose it to other companies within their group, their agents and third party service providers, law enforcement and regulatory bodies. Some of the organisations we share information with are located outside of the European Economic Area ( EEA ), including India. We ll take steps to ensure that any such transfer of information outside of the EEA is managed to protect your privacy rights. For more information on this please see our Privacy Policy or contact us. 5. How long we keep your personal information for We maintain a retention policy to ensure we keep personal information only for as long as we reasonably need it please see our Privacy Policy for further details. We need to retain personal information for the period necessary to administer the policy and support the administration of the Scheme and as long as is required/permitted by law and/or in respect of any potential dispute in relation to the policy. Currently this would

7 commonly be 7 years from the later of the date when the customer relationship ceases or a claim in payment ceases. Where individual underwriting applies but cover not subsequently taken out or cover is declined, underwriting details may be kept for a period of up to 3 years to facilitate a subsequent application or as a check against non-disclosure. 6. Your rights You have various rights in relation to your personal information, including the right to: request access to your personal information correct any mistakes on our records erase or restrict records where they are no longer required object to our use of personal information based on legitimate interests or public interests asking not to be subject to solely automated decision making if the decision produces legal or other significant effects on you move (in a structured, commonly used and machine-readable format) certain data to other providers (data portability). We will respond to your request in writing, or orally if requested, as soon as practicable and in any event not more than within one month after receipt of your request. In exceptional cases, we may extend this period by two months and we will tell you why. We may request proof of identification to verify your request. For more details in relation to your rights, including how to exercise them, please see our Privacy Policy or contact us using the details set out below. 7. Contacting us If you have any questions about how we use personal information, manage personal information within our business or if you want to exercise your rights stated above, please contact our Data Protection Officer by either ing them at DPO@aviva.com, writing to the Data Protection Officer, Aviva, One Park Place, Hatch Street, Dublin 2 or call us at (01) If you have a complaint or concern about how we use your personal information please contact us in the first instance and we will attempt to resolve the issue as soon as possible. You also have the right to lodge a complaint with the Office of the Data Protection Commission or any other relevant data protection authority. Please see our Privacy Policy (available at or on request) or contact us for further details. SECTION 8 Group Income Protection Data Protection Notice Data Protection Notice Group Income Protection Underwritten by Friends First Life Assurance Company dac (part of the Aviva Group) Please read this Data Protection Notice carefully before you complete the Declarations 1. Introduction We collect and use personal information about individuals so that we can provide insurance and pension products requested by our customers. This Data Protection Notice explains the most important aspects of how we use personal information and what rights individuals have. You can get more information about the terms we use and view our Privacy Policy at or request a copy by writing to the Data Protection Officer, Aviva, One Park Place, Hatch Street, Dublin 2 or call us on (01) This Data Protection Notice applies mainly to the lives to be insured whose information is relevant to the insurance under the policy. This Data Protection Notice also applies to the directors/signatories to this application for corporate Policy Owner or to individual Policy Owner as regards the more limited information that we will hold in respect of them (e.g. their contact details). The terms you and your are used accordingly in this Data Protection Notice. The data controller responsible for processing this personal information is Friends First Life Assurance Company dac ( we, us, our ) as the insurer of the policy issued to the employer (of the lives insured) as Policy Owner. Additional data controllers involved in the process for obtaining and maintaining insurance cover include the Policy Owner (who is employer of the lives insured), intermediary/ financial broker (who is responsible for the sale and suitability of the product) and applicable reinsurers. Risk assessment for Group Protection will be carried out on anonymised basis (i.e. without identifying personal information of the lives insured) where appropriate. We mainly process personal information of the lives insured: if individual risk assessment/underwriting applies (e.g. because cover amount exceeds our free cover limit) where a benefit is claimed under the policy administering benefits. 2. Type of Information/Where Collected We collect personal information (including name, age/dob, salary, PPSN, pension contributions, employment status/history) from you and any relevant third parties (including that authorised by the Declarations) under and in relation to the application for the policy and the administration of the policy, to include processing claims and complaints. We may need to ask for health data relevant to the policy. We recognise that information about health is particularly sensitive information. We will only collect and use such information where we need to and where it is proportionate for the purposes of the policy of insurance.

8 Health data includes (with the exception of the results of genetic tests) lives to be insured health data to include, existing or previous health conditions, medical history and lifestyle (e.g. smoking habits/history) and family health history. If you are asked to provide health data, please do not send us the results of any genetic tests carried out on you or any other relevant person. You don t have to provide us with any personal information, but if you don t provide the information we need we may not be able to proceed with the application, cover for a life or lives to be insured or claim for benefit. We will let you know what information is required to proceed with your application or any claim you make. We may also use personal information about people other than you e.g. where individual underwriting applies family health history of the lives insured. If you are providing personal information about another person we require you to let them know what information you ve shared with us, share with them this Data Protection Notice and obtain their confirmation that they have read and understand this Data Protection Notice. If you or they have any queries or concerns please contact us in one of the ways described below. We may also collect personal information: already held about you within the Aviva Group (identified in Privacy Policy), including details from previous, policies of insurance and claims; from the intermediary, financial broker or other nominated representative; from parties relevant to claim process (e.g. claimant, private investigators engaged by us, witnesses, solicitors and independent experts); from publicly available information including social media websites and online content, newspaper articles, tv, radio and other media content, court judgements, public registers and specialist databases (for example Companies Registration Office, Vision-net, Oracle, Dow Jones, SoloCheck), and (only for purposes of verifying your identity) electoral register; from other insurance companies, previous employers. 3. Legal Basis and Purposes for Use The legal basis we rely on to process personal information and the purposes for which we collect and use personal information are summarised below. Further information is set out in our Privacy Policy. (a) Personal Information (other than health data) Legal Basis for Use In order to take steps prior to entering into a contract i.e. the insurance policy For the performance of a contract i.e. the insurance policy For compliance with a legal obligation Legitimate Interests (of us and/or the Policy Owners and/or the lives insured) To protect your vital interests: Legitimate Interests (of us) Legitimate Interests (of us) Purposes for Use To consider whether (and if so on what terms) to accept the application for the policy to include: assessing the lives to be insured for underwriting/risk purposes (e.g. where outside free cover limits or other group protection parameters), determining what premiums will apply, protection against non-disclosure of material facts and preventing or detecting fraud having regard to the related administrative and regulatory requirements. To administer the policy for the Policy Owners in accordance with the policy conditions (a copy of which are available on request from us or intermediary/financial broker), including to evaluate, validate and process any claims and complaints and the prevention and detection of fraud in respect of the policy. Compliance by us with all relevant legal and regulatory obligations We may process personal information of people other than the Policy Owners, in order to consider the application for the policy and administer the policy to include processing claims and complaints for the benefit of the Policy Owners and/or the lives insured. This will only arise in exceptional circumstances where we may use and/or disclose information to protect the lives insured e.g. employer in liquidation To support the legitimate interest that we have as a business in assessing our reinsurance requirements and managing arrangements we have with reinsurers (these arrangements are necessary for risk transfer by insurers); managing our legal affairs including exercising our legal rights and defending claims; and managing our business effectively e.g. with third party service suppliers. To support other legitimate interests that we have as a business and that the insurance industry at large has to manage security including preventing, detecting, investigating and/or protecting our customers and ourselves from theft and fraud. We may use your personal information to make searches of our records, if you give us false personal information or fail to disclose personal information during the application or claims process and we suspect fraud we will record this.

9 Legitimate Interests (of us) To carry out other activities that are in the public interest Our legitimate interests to better understand our customers and improve service enhancement and business performance, this includes customer analytics; market research; processing management information; reporting (including Aviva Group reporting) for compliance, audit, statistical or research purposes; staff training; providing online services; and in the event of any portfolio transfer, merger, acquisition, disposal or other such transaction relating to our business. Where practical we will anonymise the data we analyse. We may need to use personal information to verify your identity and carry out anti-money laundering checks. Your Right to Object Please note that you have a right to object to processing of your personal information where that processing is carried out on the grounds of legitimate interests or public interest. If you do object: we will have an opportunity to demonstrate that there are compelling legitimate grounds which override your rights and freedoms or that processing is necessary for the establishment, exercise or defence of legal claims a successful objection may have consequences for our continued administration of the policy (e.g. prevent us assessing future claims and/or the policy may be cancelled) and we can discuss these if you want to object. (b) Health Data Health data is used for the purposes of set-up and underwriting of the policy of insurance, administering the policy (e.g. processing claims, handling complaints), reinsurance or fraud investigation in relation to the policy. The legal basis on which we process health data in respect of the lives to be insured is that: Irish Data Protection law allows us where necessary and proportionate to use heath data for the purposes of a policy of insurance; and/ or processing is necessary for the establishment, exercise or defence of legal claims. Where we process health data for the purpose of a policy of insurance we will take suitable and specific measures to safeguard the fundamental rights and freedoms of individuals. Further information can be found in our Privacy Policy. 4. Who we share your information with Where relevant, we may share personal information with: (1) Other Aviva Group companies, agents, professional advisers acting for us (e.g. medical practitioners, lawyers, private investigators) and third party service providers. (2) The intermediary/financial broker and at its request, third party service providers who provide services to the intermediary/financial broker. (3) Your agents and other third parties relevant to you and/or the policy, including doctors and other relevant medical practitioners, employer, previous employers, other insurance companies. (4) If we are required to do so to comply with a relevant legal or regulatory obligation: with regulatory bodies, law enforcement bodies, government departments including UK Financial Conduct Authority, UK Prudential Regulatory Authority, Central Bank of Ireland, Financial Services and Pensions Ombudsman, Revenue Commissioners/Inspector of Taxes, Gardaí, Criminal Assets Bureau, Data Protection Commission and Department of Employment Affairs and Social Protection. (5) With other insurers and financial services companies, public bodies, (either directly or using shared databases) and industry bodies such as Insurance Ireland. (6) With reinsurers who provide reinsurance services to us and for each other. Reinsurers will use your data to decide whether to provide reinsurance cover, assess and deal with reinsurance claims and to meet legal obligations. They will keep your data for the period necessary for these purposes and may need to disclose it to other companies within their group, their agents and third party service providers, law enforcement and regulatory bodies. Some of the organisations we share information with are located outside of the European Economic Area ( EEA ), including India. We ll take steps to ensure that any such transfer of information outside of the EEA is managed to protect your privacy rights. For more information on this please see our Privacy Policy or contact us.

10 5. How long we keep your personal information for We maintain a retention policy to ensure we keep personal information only for as long as we reasonably need it please see our Privacy Policy for further details. We need to retain personal information for the period necessary to administer the policy and as long as is required/permitted by law and/ or in respect of any potential dispute in relation to the policy. Currently this would commonly be 7 years from the later of the date when the customer relationship ceases or a claim in payment ceases. Where individual underwriting applies but cover not subsequently taken out or cover is declined, underwriting details may be kept for a period of up to 3 years to facilitate a subsequent application or as a check against non-disclosure. 6. Your rights You have various rights in relation to your personal information, including the right to: request access to your personal information correct any mistakes on our records erase or restrict records where they are no longer required object to our use of personal information based on legitimate interests or public interests ask not to be subject to solely automated decision making if the decision produces legal or other significant effects on you move (in a structured, commonly used and machine-readable format) certain data to other providers (data portability). We will respond to your request in writing, or orally if requested, as soon as practicable and in any event not more than within one month after receipt of your request. In exceptional cases, we may extend this period by two months and we will tell you why. We may request proof of identification to verify your request. For more details in relation to your rights, including how to exercise them, please see our Privacy Policy or contact us using the details set out below. 7. Contacting us If you have any questions about how we use personal information, manage personal information within our business or if you want to exercise your rights stated above, please contact our Data Protection Officer by either ing them at DPO@aviva.com, writing to the Data Protection Officer, Aviva, One Park Place, Hatch Street, Dublin 2 or call us at (01) If you have a complaint or concern about how we use your personal information please contact us in the first instance and we will attempt to resolve the issue as soon as possible. You also have the right to lodge a complaint with the Office of the Data Protection Commission or any other relevant data protection authority. Please see our Privacy Policy (available at or on request) or contact us for further details. SECTION 9 Group Life Insurance Employer / Trustee Declaration We apply to Aviva for this Group Protection - Life Insurance Policy to be issued to the trustee/s of the Scheme identified in this application and declare that: 1) The information in this application is true and complete and we understand the consequences for cover if this is not the case (as outlined at the start of this application). 2) We understand that the policy is conditional on the approval of the Scheme by the Revenue Commissioners as an exempt approved scheme under Chapter 1 of Part 30 of the Taxes Consolidation Act, ) We confirm that the contract effected in pursuance of this application will be held by the trustees under irrevocable trust for the purpose of providing relevant benefits as defined by chapter 1, Part 30 of the Taxes Consolidation Act, 1997 to or in respect of the member under the Scheme Rules. 4) We consent to Aviva, verbally or otherwise, seeking and receiving additional information that isn t provided on the application or where further information is required in order to process the application. I/We understand that such information will be deemed to be incorporated into this application for the purposes of 1) above. We hereby authorise the employer, the trustees, administrators and life insurance providers of relevant arrangements with information relevant to this application, and our agents, to provide such information to Aviva. 5) We agree that without further communication to us Aviva may, if they accept this application, issue a policy comprising of policy conditions on Aviva s standard terms for policies of this type (a copy of which has been made available) and a policy schedule as regards to the particulars of the policy such as the scheme name, employer(s) and level of cover. 6) We agree that the policy conditions and policy schedule, together with this application, will form the contract between Aviva and the trustees and authorise Aviva to accept instructions in relation to this application and the policy: - from the Scheme Delegate who the trustees appoint under the Scheme Rules and notify to Aviva; or - in default of such appointment, unless the trustees notify Aviva to deal directly with the trustees, from the Principal Employer

11 7) We agree and understand that even if a premium is tendered or direct debit mandate is signed, no binding contract is created until Aviva has issued the policy. 8) We the trustees are resident for tax purposes in the Republic of Ireland and have an address in the Republic of Ireland[ and we understand the consequences for cover if this is not the case (as outlined at the start of this application)]. We undertake to inform Aviva of any change in our country of residence during the life of the policy. 9) We will to provide Aviva for each anniversary date (and other times as may be required) such particulars as are necessary to enable Aviva underwrite the benefits. 10) We agree and understand that Aviva s processes may involve electronic means including, but not limited to, data entered online, the capturing of our signatures on an electronic device, the use of electronic signature or the use of a signature-free process; Aviva s processes may also (even where commenced on-line) involve manual processes and/or require wet ink signing of documents at certain points. 11) Declare that we were entitled to make disclosure of personal data that we have made to Aviva in connection with this application, and will ensure that we are similarly entitled to make any such disclosure that we make in the future, without breach of data protection law or other law. 12) We have read and understand the Group Life Data Protection Notice at section [nn]. Where we are providing information about another person (e.g. the lives to be insured/members the Scheme), we confirm that we have: let them know what information I/we have shared with Aviva shared the Data Protection Notice with them and obtained their confirmation that they have read and understand the Data Protection Notice. We understand that Aviva require for the purposes of this Application that we have done so. 13) Without limiting our obligation above we will co-operate with reasonable requests from Aviva as regards information on and compliance with our obligations at 11) and 12) above. 14) We understand that references to Aviva contained herein apply to Friends First Life Assurance Company dac, which is the company in the Aviva Group that underwrites the Insurance Policy for which we are applying. I agree to appointing as my agent under the plan. Authorised to sign for and on behalf of the employer Signature 7 Date DD MM YY Name (in block capitals) Position in company I agree this application and declaration will form the basis of the contracts proposed between the trustees and Friends First. I agree to appointing as our agent under the plan 1. Authorised to sign for and on behalf of the trustees Signature 7 Date DD MM YY 2. Trustee Name (in block capitals) Admin Agent No. Agent Contact Name

12 SECTION 10 GROUP INCOME PROTECTION - POLICYHOLDER DECLARATION I/We apply to Aviva for this Group Protection - Income Protection Policy to be issued to the employer identified in this application and declare that: 1) The information in this application is true and complete in all material respects and I/we understand the consequences for cover if this is not the case (as outlined at the start of this application). 2) I/We consent to Aviva, verbally or otherwise, seeking and receiving additional information that isn t provided on the application or where further information is required in order to process the application. I/We understand that such information will be deemed to be incorporated into this application to include for the purposes of 1) above. I/We hereby authorise the administrators and life assurance providers of relevant pension or group income protection arrangements with information relevant to this application, and our agents, to provide such information to Aviva. 3) I/We agree that without further communication to us Aviva may, if they accept this application, issue a policy comprising of policy conditions on Aviva s standard terms for policies of this type (a copy of which has been made available) and a policy schedule as regards to the particulars of the insurance policy such as the level of cover. 4) I/We agree that the policy conditions and policy schedule, together with this application, will form the contract between Aviva and us. 5) I/We agree and understand that even if a premium is tendered or direct debit mandate is signed, no binding contract is created until Aviva has issued the policy. 6) I/We are resident for tax purposes in the Republic of Ireland and have an address in the Republic of Ireland[ and I/we understand the consequences for cover if this is not the case (as outlined at the start of this application)]. I/We undertake to inform Aviva of any change in our country of residence during the life of the policy. 7) I/We will provide Aviva for each anniversary date (and other times as may be required) such particulars as are necessary to enable Aviva underwrite the benefits. 8) I/We agree and understand that Aviva s processes may involve electronic means including, but not limited to, data entered online, the capturing of our signatures on an electronic device, the use of electronic signature or the use of a signature-free process; Aviva s processes may also (even where commenced on-line) involve manual processes and/or require wet ink signing of documents at certain points. 9) I/We were entitled to make disclosure of personal data that we have made to Aviva in connection with this application, and will ensure that we are similarly entitled to make any such disclosure that we make in the future, without breach of data protection law or other law. 10) I/We have read and understand the Group Income Protection Data Protection Notice at section [nn]. Where we are providing information about another person (e.g. the lives to be insured), we confirm that we have: let them know what information I/we have shared with Aviva shared the Data Protection Notice with them and obtained their confirmation that they have read and understand the Data Protection Notice. I/we understand that Aviva require for the purposes of this Application that we have done so. 11) Without limiting our obligation above I/we will co-operate with reasonable requests from Aviva as regards information on and compliance with our obligations at 9) and 10) above. 12) I/We understand that references to Aviva contained herein apply to Friends First Life Assurance Company dac, which is the company in the Aviva Group that underwrites the Insurance Policy for which I/We are applying.

13 Our preferred method is to collect premium payments by means of Direct Debit. Please complete the Mandate below so that we can arrange the collection of the appropriate amounts. SECTION 11 SEPA DIRECT DEBIT MANDATE Unique Mandate Reference (UMR) Originator s ID number I E 6 7 S D D By signing this mandate form, you authorise (A) Friends First Life Assurance Company dac to send instructions to your bank to debit your account and (B) your bank to debit your account in accordance with the instructions from Friends First Life Assurance Company dac. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank. Please complete all the fields marked *. *Name of Account Holder *Address of Account Holder *City/postcode *Country *IBAN Account number *BIC Code Type of payment Recurrent payment By signing this mandate form, you authorise Friends First to provide at least 4 days advance notice before the first direct debit is collected from your account. *Name of account to be debited: Joint Account *Signatures for Joint Accounts requiring two signatures: 1st Account Holder 2nd Account Holder 1st Signature Date 2nd Signature Date DD MM YY DD MM YY *Name of account to be debited: Single Account * I confirm that only my signature is required on this account Account Holder * Policyholder s name, if different from name of account to be debited Signature Date DD MM YY Please return this mandate to Friends First Life Assurance Company dac and not your bank Creditors Name: Friends First Life Assurance Company dac. Creditors Address: Friends First Life Assurance Company dac Premium Collection Department, Cherrywood Business Park, Loughlinstown, Dublin 18.

14 This product is underwritten by Friends First Life Assurance Company dac. Friends First is part of Aviva Friends First Life Assurance Company dac, Friends First House, Cherrywood Business Park, Loughlinstown, Dublin 18. Friends First Life Assurance Company dac is regulated by the Central Bank of Ireland