Accepted quote reference

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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? Yes No If Yes 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 Trust and Registration Is there a trust in place? Yes No (Please note that if the answer is No you should not proceed further as we are unable to assume risk without a trust in place) What is the full scheme name as it appears on the establishing deed? What was the date the trust was first executed / / Is this a registered scheme? Yes No For registered schemes, what is the PSO/PSTR number applicable to the above deed? Important Notes: If the scheme is not registered with HMRC, Canada Life will only issue an Excepted Group Life Policy as defined in section 480 (3) of the Income Tax (Trading and Other Income) Act If a Canada Life trust deed has not been used we may not be able to assist with future documentation updates. The policy will be issued to and in the name of the trustees of the scheme. C1 Trustee details If the scheme trustee is the principal company or organisation identified above, please leave the box below blank. If the trustee is a corporate body other that the principal organisation, please enter the full name, registered address and Companies House registration number of the corporate trustee. If individual trustees have been appointed, please give full names and addresses of the trustees. If you wish, you may supply this on a separate sheet. 2

3 Section D 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? Yes No If Yes, 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 No, 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? Yes No If No please give details of any new or omitted claims. Yes No Note that if there are claims that we were not aware of, we may increase the cost shown in the quotation. Section E 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 E1 E2 Members who do not fulfil the actively at work requirement described in our Group Life Assurance 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. E3 Members who are resident outside the UK. E4 Members who travel on business outside the EU or North America. E5 Any other information requested under the Additional Requirements section of your quote No further requirements shown I have set out the details separately An actively at work condition normally applies to insured schemes where there are fewer than 50 lives and to previously uninsured 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. 3

4 Section F Scheme information 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. Can the quote data be used for inception accounts? Yes No F1 Rates and costs Lump sum unit rate(if applicable) Annual Cost DISP Unit Rate (if applicable) % Annual Cost F2 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? Yes No Are zero hour contract workers included? Yes No Are fixed term contract employees included? Yes No Are employees on temporary contracts included? Yes No Are employees on seasonal contracts to be included? Yes No If employees are to be included who fall outside the above categories please specify below. Lump Sum (LS) Death in Service pension (DISP) 4

5 F3 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 Lump sum (LS) Minimum age to Join Scheme Maximum age to join scheme Minimum service requirement Cease age DISP Do employees join the scheme on the first day they meet the age and service requirements? If No, please specify below. Yes No Lump sum scheme joining date DISP scheme joining date Is continued cover for members who leave service in receipt of an incapacity pension to be included? Yes No If Yes, what is the cease age for this category? Continued cover for members who leave service in receipt of an incapacity pension should cease no later than the expected normal pension age. F4 Pension scheme membership Lump sum Is the scheme only open to pension scheme members? Yes No Yes No If No, are different benefits provided for pension scheme members? Yes No Yes No If the answer to either of these questions is Yes, please enter the pension scheme name and the take up rate to the pension scheme below. Pension scheme name DISP 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 F2 and F3? If the answer is No, please give the pension scheme eligibility and entry criteria below. Yes No 5

6 F5 Lump sum benefit basis Please enter the benefit basis (for example 4 x salary) 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. F6 Death in service pension benefit levels Please enter the benefit basis (for example 25% of salary) for each category Escalation rate Accrual rate (if DISP is a proportion of prospective pension Pension payable to spouse or civil partner Pension continues to orphans If LPI escalation what is the maximum (2.5% or 5%)? Definition of prospective service (if accrual rate applies) Pension payable to any financial dependent Separate children s pension F7 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 LS Basic Salary Other Mid-year changes to be insured Fixed at Annual Revision Date DISP Basic Salary Other Mid year changes to be insured Fixed at 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? Yes No If Yes does this apply to all members? (If it applies to specific members please detail overleaf) What do the sacrificed amounts represent? Pension contributions Cycle to Work Childcare vouchers Others (please specify) Does a salary cap apply? If Yes, enter cap amount 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 70% of salary 6

7 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/GLA/RDF/0116 Canada Life Limited 3 Rivergate, Temple Quay, Bristol BS1 6ER Telephone