Accepted quote reference

Transcription

1 Risk details form In order to place cover with Canada Life, please make sure you: Accepted quote reference scan and or fax this form to our Bristol office in advance of the commencement of risk. The latest we can accept instruction to go on risk is 4.00pm on the day before risk is to commence. use BLOCK CAPITALS. You may attach a separate sheet showing the requested information. If you do not complete all the required fields, we may not be able to assume risk on the intended day. Section A Intermediary Financial Services Register reference number Section B Employer details Principal employer s registered name and address including postcode Principal employer s Companies House registration number Are there any other employers to be included? If please provide full details of each additional company or organisation, quoting their Companies House registration number or company status, and if a charity, their registered charity no. You may also supply further information on a separate sheet.

2 Section C Confirmation of current insurance and claims experience Are the members to be insured by this policy currently insured by a group policy with Canada Life or another provider? If, please complete the rest of this section, otherwise proceed to the next section. Name of previous insurer Is cover to be on the same basis as the previous insurer? If, please tell us what has changed in Further information at the end of this form. Have all claims that have occurred in the last five years been advised to us? If please give details of any new or omitted claims. te that if there are claims that we were not aware of, we may increase the cost shown in the quotation. Section D Confirmation of additional requirements Please refer to our quotation before completing this section. We are unable to assume risk until all additional requirements have been confirmed. Please tick the correct boxes. There are no members in this category There are members in this category (already advised to you) This is new information which I have set out separately D1 D2 D3 D4 Members who do not fulfil the actively at work requirement described in our Group Income Protection Technical Guide (including members in receipt of disability benefit absent through sickness or injury for a period greater than 3 months or working reduced hours due to sickness or injury). Members who have been restricted, declined, postponed or accepted on non standard terms. Members who are resident outside the UK. Members who travel on business outside the EU or rth America. D5 Any other information requested under the Additional Requirements section of your quote. further requirements shown I have set out the details separately An actively at work condition applies to insured schemes. The requirements for employees who do not satisfy the actively at work requirements are shown in the technical guide. We reserve the right to amend or withdraw our quotation if there are any members who have not been underwritten on standard terms, or if there are any long term absentees, that you have not previously told us about. Employees resident outside the UK are not included unless we have agreed to include them. 2

3 Section E Scheme information Scheme Name Commencement date / / Annual revision date each year (day/month) / Commission rate % Payment frequency: Monthly Annually Please note that our rates and costs will change if the payment frequency or commission shown above are different from the terms shown on the quotation. If these terms have altered please ask to re-quote on the correct basis before asking us to assume risk. Unit Rate (if applicable) % Annual Cost Can the quote data be used for inception accounts? E1 Scheme eligibility If there are different benefits for different categories of employee, please supply clear eligibility definitions for each category. Please note that we cannot accept categories that include individual s names. Where a category includes the term Senior please provide clarification of what this means so that we can be sure the eligibility is clear and not discretionary. Is the eligibility All Permanent Employees? Are zero hour contract workers included? Are fixed term contract employees included? Are employees on temporary contracts included? Are employees on seasonal contracts to be included? Eligibility if not covered by the above tick box selections. E2 Entry ages, service requirement and age at which cover ceases If maximum entry age and/or cease age are linked to state pensionable age, please write SPA in the relevant boxes Minimum age to join scheme Maximum age to join scheme Minimum services requirement Cease age Do employees join the scheme on the first day they meet the age and service requirements? If, please specify below. Scheme joining date 3

4 E3 Pension scheme membership Is the scheme only open to pension scheme members? If, are different benefits provided for pension scheme members? Are pension scheme contributions insured? If the answer to either of these questions is, please enter the pension scheme name and the take up rate to the pension scheme below. Pension scheme name Take up rate % The take up rate is the number of pension scheme members divided by the number of employees eligible to join the pension scheme, multiplied by 100. Is the pension scheme eligibility and entry criteria the same as in E1 and E2? If the answer is, please give the pension scheme eligibility and entry criteria below. E4 Basic benefit basis Please enter the benefit basis (for example 75% of salary with no offset) for each category Where a category includes the term Senior please provide clarification of what this means so that we can be sure the eligibility is clear and not discretionary. If a category with higher benefits has fewer than 5 members please let us know how long this category has been insured on this basis. E5 Supplementary benefit Pension Scheme Contributions Please enter amount(s) and who for, for example 10% for XYZ pension scheme members. If not insured write t insured. Pension scheme contributions Employers National Insurance contributions: Insured t insured 4

5 E6 Escalation, deferred period and claim payment period Escalation rate Deferred period Unlimited claim payment period Limited payment period (specify years) E7 Definition of incapacity Standard Suited occupation Standard switching to suited occupation after 2 years E8 Employer s lump sum (limited payment period schemes only) Is an employer s lump sum required? If, please answer the following questions. What is the definition of disability to be used in assessing the payment of the lump sum? Standard What lump sum is required Suited occupation x salary x income benefit fixed amount E9 Salary definition Please tick the relevant definition of salary and what date the salary is applicable. If the definition is not basic salary, please give the definition in the box below. Definition Date Applicable Basic Salary Other Date of incapacity Annual Revision Date Other (please specify) Please check that the above definition is suitable for any zero hour, fixed term contractors, seasonal or temporary employees and let us know if it is different. For example, is basic salary appropriate for zero hour contract employees? Does salary sacrifice apply? If does this apply to all members? (If it applies to specific members please detail overleaf) What do the sacrificed amounts represent? Pension contributions (see note at bottom of this page) Cycle to Work Childcare vouchers Others (please specify) If salary sacrifice applies we need to understand what we are being asked to insure and we may need to impose terms. Please contact us if any sacrificed amount exceeds 15% of salary. 5

6 Further information: Please scan and the completed form to prior to the commencement date. Alternatively, you can fax the completed form to For flexible benefits schemes, please also complete the Flexible benefit policies additional risk details form. Our forms are available to download from our website: Canada Life Limited, registered in England no Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA. CLFIS (UK) Limited, registered in England no is an associate company of Canada Life Limited. Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA. Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. F/GIP/RDF/0116 Canada Life Limited 3 Rivergate, Temple Quay, Bristol BS1 6ER Telephone