Application form reference number (Obtained once you start the application online at pruprotect.co.uk) Relevant Life Cover • Application / Data Capture form Look for this symbol, which highlights important guidance notes or instructions throughout this form How Advisers can use this form Collect the information required using this form and then submit the application online at pruprotect.co.uk a) Data capture form for online submission •• •• •• Submitting your application online at pruprotect.co.uk means that you have an immediate underwriting decision or details of other information required Complete to the end of section I and also collect the payment details on page 20 to submit online Your client(s) must also sign the Access to Medical Records Act Declaration on page 24. Detach this declaration ONLY and post it to: PruProtect, New Business, Stirling FK9 4UE OR b) Paper submission •• •• •• Complete all sections Your client(s) must sign the Access to Medical Records Act Declaration on page 24, the payment instruction on page 20 and the client declaration, authority and consent starting on page 25. Post the paper application to PruProtect, New Business, Stirling FK9 4UE Contents Important information for the plan holder / life(s) assured 2 A - Client information - details 3 B - Plan details 4 C-About you 5 D-Personal 7 H - Payment details 20 E - Doctor’s details 17 I-Access to Medical Report Act 23 F-Policy owner details 18 G-Policy information 19 J -Full paper application client declaration, authority and consent 25 Important information for the plan holder / life(s) assured Please use black ink, BLOCK LETTERS and tick or complete answers as appropriate. Please take care to answer the questions on this form honestly and fully. If you miss any information out, or give us misleading information, this may mean that a future claim will not be paid. In addition, this could also delay the processing of your application. If someone else fills this form in for you (for example, your financial adviser), please check that all the details are correct before you sign the declaration. You are responsible for all the answers you or your financial adviser provide on this application. If you make a mistake please cross it out, put in the correct word or words and initial next to the correction. If you would prefer, you may complete the medical questions in private and return the Lifestyle details section direct to our Chief Medical Officer. Please indicate on this form if you have done so. It is very important that you tell us if there is a change to any of the following between completion of this form and your application being accepted •• •• •• •• •• •• Your personal health Your family history Your occupation Your participation in any hazardous leisure activities Your travel or residence Your lifestyle (smoking/alcohol consumption etc) If you do not, the plan may be cancelled and will result in non-payment of a claim. Information about genetic tests If this application, taken together with any other insurance policies you already have, is for Life Cover up to a sum of £500,000 you need not disclose any genetic test you may have had. You need not disclose the result of any genetic test undertaken in the context of research. Genetic test results need only be disclosed where the sum exceeds either £500,000 for Life Cover and their use by insurers has been independently approved. You may, of course, disclose any genetic test result which is in your favour. If you either have a family history of, are experiencing symptoms of, or are having treatment for, a genetic condition, you must tell us. Further information is available on request which fully explains this policy and details those genetic tests approved for use by insurers. 2 A. Client information – details Personal information The Life Assured Title Mr Mrs Miss Ms Other First name (s) Surname Date of birth D D M M Y Y Y Y Marital status Gender Are you a smoker? Yes No Occupation Employment status Annual gross salary Contact information Should our tele-underwriters need to contact your client(s), please choose the preferred contact times. We will contact your client between Monday and Friday. Which telephone number should we use? Please provide at least one contact number The Life Assured No Preference 9am – 8pm Morning 9am – 12pm Afternoon 12pm – 4pm Evening 4pm – 8pm Work Mobile Home Work Mobile Home Email address Current address Postcode 3 A. Client information – additional details 1.Do you already have any Life Cover with Prudential, PruProtect or Scottish Amicable? Yes No If ‘Yes’ please provide the relevant contract number(s) 2.Will you be cancelling any Life Cover outlined in question 1 above when your PruProtect plan starts? Yes No If you have a presale number please enter it here IMPORTANT NOTE FOR ADVISERS: If you have contacted the pre-sale advice team you may have been given a presale number. To avoid the application being referred to underwriting unnecessarily, if you were indicated standard terms or a rating for BMI/waist measurement only, please do not enter your pre-sales advice number. However, when keying the application into the online apply system, if the final underwriting outcome differs from that advised, please click on ‘Refer to Underwriting’ when submitting the application. Height feet inches or centimetres Weight stones pounds or kilograms Waist size inches or centimetres B. Plan details 1. What amount do you want for your plan account? (the amount of your plan account is equal to the amount of your Life Cover) £ INFORMATION: A plan account is an amount that determines how much we can pay out if you make a claim. For more about this see the full plan provisions document. 2. Plan details 2.1What term do you want for your plan account? (the minimum term is 1 year) 2.2Do you want your premiums for benefits linked to the plan account to be guaranteed or reviewable? 2.3Do you want your plan to be year(s) Guaranteed Reviewable Indexed Level IMPORTANT: If you choose a level plan, the plan account stays the same unless you make a successful claim or change cover. If you choose an indexed plan, at each plan anniversary your cover will increase by Retail Prices Index (RPI). Premiums will increase by RPI plus 2.5%. 4 C. About you 1. Other/existing cover 1.1 W ithin the last 12 months have you applied for any other cover with PruProtect, regardless of whether a policy has been issued or not? Yes No 1.2 D o you intend to submit an additional application to PruProtect for Life Cover at this time? Yes No 1.3 W ithin the last 12 months, have you been declined for life cover by any other company? Yes No 1.4 If ‘Yes’ please provide full details of type of cover and reason declined. 2.Occupation 2.1 W hat is your main occupation? IMPORTANT: Additional information may be required for specific occupations, such as percentage of time working at heights or whether working on oil rigs outside the North Sea or UK waters. Please capture these details if applicable. 2.2 D o you work in or with the armed forces or are you a member of the territorial army or a reservist? Yes No If ‘Yes’ please provide answers to the following: • hat area of the armed forces do you W serve in and are you regular forces, TA, reservist or civilian? • re you currently serving or due to go on a A tour of duty to an active theatre of operations within the next 6 months? • o your normal duties involve: bomb disposal, D mine clearance, diving, parachuting or flying in fast jets or ‘attack’ helicopters? (Details required). 5 C. About you - continued 3.Travel/residency 3.1 Is your primary country of residence OUTSIDE the UK (defined as England, Scotland, Wales or Northern Ireland)? Yes No uring the next 12 months do you intend 3.2 D spending longer than 3 months in total outside the UK, Europe, Australia, New Zealand, North America or Canada? Yes No 3.3 In the last 5 years have you worked or stayed for any continuous period longer than 6 months outside the UK, Europe, Australia, New Zealand, North America or Canada? Yes No Yes No You should answer ‘Yes’ if you reside in the Channel Islands, IOM, Eire (Republic of Ireland) or anywhere else other than the UK. 4. Hazardous pursuits/hobbies 4.1 D o you take part in, or intend to start any pastime which involves additional risk of accident, e.g. motor sport, private flying, climbing, diving, caving or extreme sports? You can ignore one off experiences, or general sports, e.g. rugby or football. If ‘Yes’ please complete the following questionnaire: 6 • ame of activity(s) – include names of ALL N aspects of the activity you take part in. If activity is skiing, please advise whether you ever go off piste, heli-skiing or ski mountaineering • Please list any qualification(s) + years held • here do you take part in this activity(s) W i.e. venue type, area of the world etc? • How many times a year do you take part? • Do you ever take part alone? Yes • I f applicable, what heights/depths do you go to? Height m Depth m Years held No D. Personal 1.Lifestyle 1.1 H ave you smoked or used tobacco products in the past 12 months (includes cigarettes, cigars, pipe, loose tobacco, any nicotine replacement therapy and electronic cigarettes). We will carry out random tests to confirm non-smoker status. Yes No Yes No Yes No Yes No Yes No If ‘Yes’ please enter the number of cigarettes smoked per day. 1.2 D o you regularly drink more than 30 units of alcohol per week? (1 unit=25ml of spirits or a small glass of wine or a half pint of beer or lager.) If ‘Yes’ please include details of number of units you drink per week, whether you have regularly exceeded this amount in past, whether you drink during the course of the week or weekends only, and whether you have had any accidents or been banned from driving due to alcohol in the past 5 years. 1.3 H ave you ever asked for, or been given advice to reduce your alcohol consumption or required any treatment or support to help you stop drinking? If ‘Yes’ please provide full details of treatment or advice given. 1.4 In the last 10 years have you ever taken recreational drugs such as cannabis, ecstasy, cocaine, methadone, heroin, anabolic steroids or similar substances? If ‘Yes’ please provide details including, type of drugs used, dates, how often (i.e. regularly or as an experiment) and circumstances (i.e. party, university etc). 1.5 H ave you ever tested positive for HIV, Hepatitis B or C or are you awaiting the results of such a test? IMPORTANT: If the result is negative, the fact of having an HIV test will not, in itself, have any effect on your acceptance terms for insurance. If ‘Yes’ please provide details on which test(s) you are awaiting results for. IMPORTANT: This information may be sent in confidence to our chief medical officer. 7 D. Personal - continued 2. Family History Before the age of 60, have either of your parents or any siblings been diagnosed with, or died from, any of the following: (Please answer ‘No’ if you do not know the medical history of your natural parents or siblings). 2.1 B reast, ovarian, colon or bowel cancer, heart attack, angina, cardiomyopathy, stroke or diabetes, multiple sclerosis or muscular dystrophy, Parkinson’s disease, Yes Alzheimer’s, Huntington’s or motor neurone disease, polycystic kidney disease or haemochromatosis No If ‘Yes’ please provide details of age of relative, relationship and whether you have had any screening or investigations for this condition yourself 3. Your Health Have you ever had or do you currently have any of the following: (If ‘Yes’ please complete the following questions:). ancer, leukaemia, Hodgkin’s disease, 3.1 C lymphoma, brain or spinal tumour Yes No 3.2 H eart disease or disorder, including heart attack, angina, cardiomyopathy, heart murmur, heart valve defect or heart surgery or procedure Yes No 3.3 S troke, transient ischaemic attack (TIA), brain haemorrhage or permanent brain injury through an accident Yes No 3.4 M ultiple sclerosis, optic neuritis, epilepsy, paralysis, muscular dystrophy, Parkinson’s disease, dementia or Alzheimer’s disease, cerebral palsy, motor neurone disease or any disorders of the brain or nerves Yes No 3.5 D isease or disorder of the blood vessels, including circulation problems in the legs Yes No 3.6 Diabetes or sugar in the urine Yes No 3.7 M ental illness that has required hospital treatment as an inpatient Yes No IMPORTANT: Please complete the additional medical questionnaire(s) for each disclosure and provide as much information as possible. 8 Medical questionnaire – disclosure 1 Only complete if you have answered ‘Yes’ to any parts of questions 2.1 – 3.7 in Section D, on pages 8. Cancer – please provide the histology and staging if known Mental illness – please advise whether there have been any episodes of self harm or suicide attempts Diabetes – please complete the separate questionnaire on page 12 NOTE: Please note that not all questions will be relevant for each medical disclosure made. The Life Assured 1. What is the medical condition? 2. Has the diagnosis been confirmed? Yes No 3. Are you having any investigations into the cause of your symptoms? Yes No i)When did the symptoms occur? (ii) When did you last have symptoms? 4. Do you have recurrent symptoms? (i) D D M M Y Y Y Y D D M M Y Y Y Y Yes No Yes No Yes No If ‘Yes’, please give details of how many episodes or attacks of symptoms you have had since onset of condition and describe the nature and severity of the symptoms 5. Do they restrict you in any way? (i) If ‘Yes’, please give details of the problems experienced 6. Have you seen a specialist for the condition? (i)If ‘Yes’, please give their name and address, the last date you attended and whether you are still attending them or not. 9 Medical questionnaire – disclosure 1 - continued The Life Assured 7. What medical investigations have been performed? Results: 8. What were the results (if known) and the dates they were done? D D M M 9.Have all investigations now been completed? Yes No 10. Are you waiting for any follow-ups or reviews? Yes No (i) When did you last see your GP with this condition? 11.How many times have you been admitted to hospital for this condition and when was the last time? 12.When was the last time you went to hospital as an outpatient for investigations or check-ups for this condition? 13. What treatment has been prescribed? D D M M Y Y Y Y Y Y Y Y (i) No.of admissions (ii) Date D D D M D M M M Y Y Y Y Y Y Y Y Y Y Y Y Y Y Name of treatment: (This should include details of all oral steroid prescriptions, e.g. prednisolone.) Please continue on a separate sheet if necessary. Dose (if known): (i)Is the treatment continuing? Yes (ii)If ‘No’, when did it stop? 14.Is any operation planned or being considered? 10 D D No M Yes M No (i)What type of operation? (ii)If ‘Yes’, when is it planned? D D M M Y Y Medical questionnaire – disclosure 1 - continued The Life Assured 15. H ave you required time off work? Yes No (i)If ‘Yes’, please give the date you were first absent from work. D D M M Y Y Y Y (ii)The date you returned to work. D D M M Y Y Y Y If you need to advise us of any other disclosures please continue on a separate sheet. Medical questionnaire for diabetes only - please complete the following questions 1.What type of diabetes do you have? 2.When was your diabetes first diagnosed? 3. Have you ever had a heart attack, angina, stroke, blood vessel disease, circulation problems in your legs or feet, or kidney problems? Type 1 M Type 2 M Y Y Yes No Yes No Y Y Y Y If ‘Yes’ please provide as much information as possible. 4.Have you ever had a diabetic coma? If ‘Yes’ please provide as much information as possible, including date(s). 5.When was your last diabetic review, either with your GP or clinic/hospital? D D M M Y Y 6. If known, what was the result of your last HbA1c? 7. If known, what was the result of your last blood pressure reading? 8. Are you on medication to either treat high blood pressure, or as a preventative measure to maintain your blood pressure at acceptable levels? Yes No 11 Medical questionnaire for diabetes only - please complete the following questions - continued 9.If known, what was the result of your last cholesterol level? 10.Are you on medication to either treat raised cholesterol, or as a preventative measure to maintain your cholesterol at acceptable levels? Yes No 11.Have you ever had any ulcers, numbness, tingling or loss of sensation in your fingers, toes, feet or legs? Yes No 12.Have you ever had protein in your urine? Yes No 13.Have you ever had any diabetic eye problems? Yes No If ‘Yes’ please provide as much information as possible. I f ‘Yes’ please provide as much information as possible, including nature of any treatment received or planned. D. Personal - continued 4. Your health in the last 5 years Apart from any condition you have already told us about, have you had any of the following in the last 5 years: (If ‘No’ please go to question F5 on page 18). 12 4.1Lump, cyst, growth or skin lesion of any kind, or a mole or freckle that has bled, become painful, itchy, changed colour or increased in size Yes No 4.2Raised blood pressure or raised cholesterol, chest pain, palpitations or irregular heart beat Yes No 4.3Numbness, tremor, tingling, dizziness, facial pain or visual disturbance including blurred or double vision Yes No 4.4Seizures, fits, fainting or blackouts Yes No D. Personal - continued 4. Your health in the last 5 years 4.5Any disorder of the digestive system, liver, stomach, oesophagus, pancreas, colon or bowel, including gastric ulcer, hepatitis, pancreatitis, colitis or Crohn’s disease Yes No IMPORTANT: Ignore minor indigestion, heartburn, appendicitis (operated and fully recovered) or irritable bowel syndrome (IBS) that only cause occasional mild discomfort and for which you have not required investigation or hospital referral and none are planned. 4.6Any disorder of the kidneys, bladder or prostate, including blood or protein in the urine, urinary tract infection or prostatitis. Yes No 4.7Any mental disorder, including stress, anxiety, panic attacks, depression, nervous breakdowns or eating disorders. Yes No 4.8Any respiratory or lung disorder, including asthma, bronchitis, emphysema or pulmonary fibrosis. Yes No 4.9Any form of arthritis or ankylosing spondylitis. Yes No 4.9.1Any disorder of the thyroid adrenal or pituitary glands. Yes No 4.9.2Anaemia or blood disorder. Yes No 4.9.3Suffered from continuous fatigue, tiredness or fibromyalgia? Yes No 4.9.4Had any pain or other problems relating to your back, neck, joints, bones or muscles, including arthritis, slipped disc, rheumatism or gout. Yes No IMPORTANT: Simple muscle strain, sprains or fractures of limbs that you have fully recovered from can be ignored. 4.9.5Had any disorder of the eyes including blindness or problems with your sight? Yes No IMPORTANT: Sight problems fully corrected by glasses or contact lenses, conjunctivitis can be ignored. 4.9.6Had any disorder of the ears including deafness or difficulty hearing (Ear syringing can be ignored). Yes No 4.9.7Had any disease of the skin, including psoriasis or dermatitis. Yes No 4.9.8Required more than 2 weeks off work for any medical condition, illness or injury not already mentioned. Yes No IMPORTANT: If answered ‘Yes’ to any of these questions please complete the additional medical questionnaire(s) for each disclosure and provide as much information as possible. 13 Medical questionnaire – disclosure 2 Only complete if you have answered ‘Yes’ to any parts of questions 4.1 – 4.9.8 in Section D, on pages 12-13. Mental illness – please advise whether there have been any episodes of self harm or suicide attempts NOTE: Please note that not all questions will be relevant for each medical disclosure made. The Life Assured 1.What is the medical condition? 2.Has the diagnosis been confirmed? Yes No 3. Are you having any investigations into the cause of your symptoms? Yes No i)When did the symptoms occur? D D M M Y Y Y Y (ii)When did you last have symptoms? D D M M Y Y Y Y 4.Do you have recurrent symptoms? No Yes No Yes No (i) If ‘Yes’, please give details of the problems experienced. 6. Have you seen a specialist for the condition? (i)If ‘Yes’, please give their name and address, the last date you attended and whether you are still attending them or not 7. What medical investigations have been performed? 14 (i)If ‘Yes’, please give details of how many episodes or attacks of symptoms you have had since onset of condition and describe the nature and severity of the symptoms. 5.Do they restrict you in any way? Yes Medical questionnaire – disclosure 2 - continued The Life Assured Results: 8. What were the results (if known) and the dates they were done? D D M M 9.Have all investigations now been completed? Yes No 10.Are you waiting for any follow-ups or reviews? Yes No (i) When did you last see your GP with this condition? 11.How many times have you been admitted to hospital for this condition and when was the last time? D D M M Y Y Y Y Y Y Y Y (i) No.of admissions (ii)Date D D M M Y Y Y Y 12.When was the last time you went to hospital as an outpatient for investigations or check-ups for this condition? 13.What treatment has been prescribed? (This should include details of all oral steroid prescriptions, e.g. prednisolone.) Please continue on a separate sheet if necessary. (i)Is the treatment continuing? (ii)If ‘No’, when did it stop? 14.Is any operation planned or being considered? Name of treatment: Dose (if known): Yes D D Yes No M M Y Y Y Y Y Y Y Y No (i) If ‘Yes’, what type of operation? (ii)When is it planned? D 15.Have you required time off work? Yes D M M No (i)If ‘Yes’, please give the date you were first absent from work D D M M Y Y Y Y (ii)The date you returned to work. D D M M Y Y Y Y If you need to advise us of any other disclosures please continue on a separate sheet. 15 D. Personal - continued You do not need to tell us about any of the following minor conditions or treatments: Acne Haemorrhoids/piles Shingles Appendicitis (operated and fully recovered) Hay fever Simple fracture of limbs (fully recovered) Athletes foot HRT (no investigations involved) Sprains (fully recovered) Indigestion/heartburn/IBS (no investigations required) Thrush Infertility treatment Tonsillitis Allergic rhinitis Bunion In growing toe nail Cold sore Uncomplicated pregnancy/caesarean Colds/flu Miscarriage/termination Common childhood diseases (fully recovered) Muscle strain (fully recovered) Conjunctivitis Contraception Vasectomy Routine cervical smear (normal result) Verruca Routine scan/blood test for pregnancy Wisdom teeth removed Ear syringing Routine wellman/woman check (normal results) Food poisoning (fully recovered) 5. Your health in the last 5 years Within the last 5 years have you: 5.1 R eceived any form of medical attention, including any surgical procedures at a hospital for any condition that you have not already told us about. Yes No IMPORTANT: See list of minor conditions and treatment that can be ignored 5.2 Undergone any investigation, x-ray, scan or blood test for any condition that you have not already told us about Yes No IMPORTANT: See list of minor conditions and treatment that can be ignored 5.3 In the last 6 months have you taken or been prescribed drugs, medicines, tablets or any other form of treatment for any condition you have not already told us about? Yes No IMPORTANT: See list of minor conditions and treatment that can be ignored 5.4 In the last 6 months have you experienced any unintentional or unexplained weight loss? If answered ‘Yes’ to any of these questions please provide as much information as possible. 16 Vaccinations and inoculations Yes No D. Personal - continued 6. Current health re you waiting the results or an 6.1 A appointment for any blood tests, cervical smears, scans, investigations, hospital or specialist referrals, surgery or medical procedures? Yes No Yes No If answered ‘Yes’ please provide as much information as possible. 6.2 A re you aware of any medical condition or symptoms where you intend to seek medical advice? If answered ‘Yes’ please provide as much information as possible. E. Doctor details Name of doctor Clinic/surgery address Postcode Telephone number 17 F. Policy owner details Company Who is the owner of this policy? – always post documents Sole trader Partnership or LLP (Limited Liability Partnership) IMPORTANT: By selecting ‘trust’ as a policy owner, this does not mean that the policy has been written into trust. If you wish to do this please send the original trust documents to PruProtect, New Business, Stirling, FK9 4UE IMPORTANT: If a ‘trust/company/one or more individuals’ has been selected as a policy owner then please complete the following details: Company/Sole Trader/Partnership - LLP Title Mr Mrs Miss Ms First name Surname Date of birth Telephone - mobile number Telephone - home number Telephone - work number D D M M Email address Address for correspondence Postcode Relationship to the life(s) assured Do you want correspondence to go to this policy owner? 18 Yes No Y Y Y Y Other G. Policy information Adviser information (complete all questions on this page) 1. FSA Regulatory No OR*Other UK/EU Regulator RI’s first name 2. Agency details RI’s surname PruProtect agency number e.g.123456X 3. Advisers that only have permissions to carry out insurance mediation on non-investment insurance contracts (i.e. pure protection business under the Insurance Conduct of Business “ICOBS” regime) will only be able to answer question 1.1 as “No” since they will not have regulatory permissions to advise or arrange investment business. Advisers who hold permissions to advise or arrange investment business as well as non-investment insurance contracts will need to consider whether this quote/application for PruProtect is associated with advice on investment business and answer question 1.1 as ‘Yes’ or ‘No’ as appropriate. 3.1Is the protection sale associated with advice on investment business as per the FSA Retail Distribution Review? Yes No (i) Commission 3.2Will you be remunerated on this PruProtect business by: (ii) Fee or other adviser charge (iii) Mix of commission and fee or other adviser charge 3.3If you are being remunerated by commission (whether in full or in part), are you intending to rebate/sacrifice a proportion of commission? If so, what percentage of commission is to be discounted (rebated)? 3.4Do you want to disclose the commission on the illustration? (See important note i below.) % Yes No IMPORTANT: Advisers that answered question 3.1 as ‘Yes’ and who are being remunerated for any subsequent PruProtect policy by commission (Q3.2(i) or (iii)) are required under FSA rules to disclose the commission on the illustration, and in this circumstance, question 3.4 should be answered as ‘Yes’. 4. Policy correspondence and options NOTE: You have the choice to receive your correspondence from PruProtect electronically via a secure inbox? Simply log on to the Intermediary Zone, go to ‘Profile Details’ then ‘Application alerts and communication preference’ and select your preferred correspondence option – either electronic or post. IMPORTANT: If you are applying for Health Cover, you can only choose for the acceptance letter and plan documents to be sent direct to the owner with a copy to you. 4.1We will send you correspondence regarding your policy via email, or via a secure online inbox located on our Member Zone (pruprotect.co.uk/member). To do so please supply your preferred email address. 4.2If you wish to receive your policy correspondence via post only, tick here 4.3 Acceptance letter to: 4.4Plan documents to: Direct to owner with copy to you Both to you Direct to owner with copy to you Both to you 19 H. Payment details 1. How does your client wish to pay their premiums? Monthly Annually IMPORTANT: If your client has selected monthly, premiums must be paid by direct debit. If your client has selected annual, the plan premium can be paid for by either direct debit, Electronic Fund Transfer (EFT) or Telegraphic Transfer (TT). Electronic Fund Transfers (EFT) and Telegraphic Transfers (TT) must be made into the following account. Please ensure you include the policy number as the reference to avoid delays in allocating the payment to the policy. Bank account name: Pru Elec Rec Business Account Bank: HSBC Sort Code: 400250 Bank account number: 51279254 Reference number: Your policy number followed by AB 2. Complete for clients paying by direct debit. 2.1 How does your client wish to complete their direct debit instruction? Paperless Paper with client signature 2.2 I have chosen to obtain client signatures on direct debit: Yes 2.3 F irst (or only) life assured name, or payer name (To be completed by the financial adviser.) 2.4 D ate of birth (To be completed by the financial adviser.) 2.5 On what date of the month do you want us to collect your premiums? (This must be between the 1st and 28th of the month.) D D No M M Y Y Y Y of the month IMPORTANT: If your client has elected to pay via Direct Debit please complete the Direct Debit form on page 21 20 Instruction to your Bank or Building Society to pay Direct Debits PruProtect is a trading name of Prudential Health Services Limited. Registered offices at Laurence Pountney Hill, London, EC4R 0HH. Please fill in the form and send to: FREEPOST PRUPROTECT, Stirling, FK9 4UE Name and full postal address of your Bank or Building Society To: The Manager Bank or Building Society Service user number 5 9 9 6 7 5 Reference number Postcode Name(s) of Account Holder(s) Branch Sort Code Instruction to your Bank or Building Society Please pay PruProtect Direct Debits from the account detailed in this Instruction subject to the safeguards assured by the Direct Debit Guarantee. I understand that this Instruction may remain with PruProtect and, if so, details will be passed electronically to my Bank/Building Society. Signature(s) Bank/Building Society account number Date Banks and Building Societies may not accept Direct Debit Instructions for some types of account This guarantee should be detached and retained by the Payer. The Direct Debit Guarantee •• This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. ••If there are any changes to the amount, date or frequency of your Direct Debit PruProtect will notify you at least 5 working days in advance of your account being debited or as otherwise agreed. If you request PruProtect to collect a payment, confirmation of the amount and date will be given to you at the time of the request. ••If an error is made in the payment of your Direct Debit by PruProtect 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 PruProtect 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. 21 This guarantee should be detached and retained by the Payer. The Direct Debit Guarantee 22 IMPORTANT: Please read and sign this declaration relating to your medical records. I. Access to Medical Report Act We may need to get medical reports to support your claim, 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. Your rights under the Act are as follows: You do not need to give your permission, but if you do not, we may not be able to go ahead with your claim. You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to keep the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us. If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date. If you think that any part of the report is not correct or is misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him or her to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others. The medical report your doctor fills in asks about the following: •• •• •• •• •• •• Your current health Any care, medication or treatment you are currently receiving The results of referrals or tests you are waiting for Any time off work in the last three years Your past health Details of any relevant illness, trauma or referrals for specialist advice or treatment, hospital admissions, consultations with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of: —— malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually worsening) diseases; —— musculo-skeletal disease or injury, for example, arthritis, rheumatism, back problems or any other disorder of the joints or muscles; We have asked your doctor not to reveal information about: •• Negative tests for HIV, hepatitis B or C; •• Any sexually-transmitted diseases unless there could be long-term effects on your health; or •• Predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from The information you and your doctor provide about your health may result in us: •• Refusing to provide insurance; •• Increasing premiums above standard rates; or •• Setting premiums at standard rates If you have any questions about your rights under the Act or questions relating to the process of getting, assessing or storing medical information, please write to: Chief Medical Officer, PruProtect, Stirling FK9 4UE Important notes Claim payments will not start until we have assessed and accepted your claim. During this period, premiums must be kept up to date. We may ask you to contact your doctor if we are waiting for reports which we have asked for. If we ask you to come for a medical examination, we will need to share the application information with another company we have authorised. They will make the arrangements for the examination to take place. We may need to send your claim form and relevant medical reports and financial information to our reinsurers for their opinion. Or, we may need to send them at a later stage for purposes relating to managing the claim. You can get details of general reassurance principles and details of any company we use to assess your claim, from our head office: Claims, PruProtect, Stirling FK9 4UE —— anxiety, depression, neurosis (such as phobias, obsessions We have a confidentiality policy in place which means we hold your and so on), psychosis (a mental disorder where you lose medical information securely and access is limited to authorised individuals who need to see it. contact with reality), stress or fatigue; —— suicidal thoughts or attempts at suicide; or —— conditions related to drug or alcohol misuse or smoking or chewing tobacco •• Details of any biopsies, blood tests, electrocardiograms (heart tests), height, weight if measured in the last two years, urinalyses (tests on urine), x-rays or other investigations •• Any blood pressure readings in the last three years •• Any history of disease among your parents or brothers or sisters that you have told your doctor about 23 IMPORTANT: Please read and sign this declaration relating to your medical records. I. Access to Medical Report Act - continued Declaration How we use your personal data You are entitled to ask for a copy of our standard terms and conditions and a copy of your application form at any time. It is our policy to obtain a random sample of medical reports shortly after acceptance of insurance contracts to monitor the accuracy and completeness of the information given. By signing this declaration you will be giving us the right to request a medical report. We will write to tell you if we require such a report. Your rights under the Access to Medical Reports Act remain the same. In the event that the medical report shows that you failed to disclose a fact that it would be reasonable to expect you to disclose, we reserve the right to reconsider the terms offered to you or cancel the policy. Please refer to page 25 for the data protection notice. If you have any questions about this please write to: Data Protection Co-ordinator, PruProtect, Marshall Point, 4 Richmond Gardens, Bournemouth BH1 1JD For certain products we will need to process sensitive personal information such as health information. By signing and returning this form, you consent to us processing your sensitive information. The Prudential Assurance Company Limited is part of the Prudential group of companies which at the time of printing includes Prudential UK & Europe, the M&G Investments Group, Prudential Corporation Asia, Jackson National Life, and PPM America Inc (indirect wholly owned subsidiary). ••I/We agree to you asking any doctor I/we have consulted about my/our physical or mental health to provide medical information so you may assess my/our proposal. You may gather relevant information from other insurers about any other applications for life, critical illness, sickness, disability, accident or private medical insurance that I/we have applied for. I/We authorise those asked to provide medical information when they see a copy of this consent form. This form allows you to gather medical reports within six months of the start of the Plan, or after my/our death, to support any claim made on the Plan proceeds. •• This information can also be used to maintain management information for business analysis. •• I/We have read the declaration, important notes and information relating to my rights under the Access to Medical Reports Act 1988. Signature of Life Assured Date of birth Full name I do not want to see the report before it is sent to the company. D D M M Y Y Y Y D D M M Y Y Y Y I do want to see the report before it is sent to the company. Signature Date To be completed by the Financial Adviser If you are applying online, please record the application reference number in the box below, as shown on the Intermediary Zone pruprotect.co.uk Application reference number: 24 Please fax this completed form to PruProtect at 0870 240 0937 or post to PruProtect, New Business, Stirling FK9 4UE. IMPORTANT: Please complete this section with your client(s) if you are using this document as a full paper application form J. Full paper application client declaration, authority and consent Declaration How we use your personal data Data Protection Notice I/We the applicant(s) declare that, to the best of my/our knowledge and belief, the information on this form is true and complete and agree that the terms of this application and declaration and any statements made by the life or lives to be assured to PruProtect’s medical examiner together with PruProtect’s letter of acceptance will be deemed to form part of any resultant contracts. Why you should read this notice I/We will inform you immediately of any changes that occur before the application is accepted. I/We understand that failure to do so may result in the contract being declared void, and that a claim for the proceeds may not be paid. *I/We authorise my/our financial adviser to act on my/our behalf to amend the sum(s) to be assured or term of the assurance applied for to correspond with any alteration in detail of the mortgage from that set out in this application and to agree the commencement date of the plan with PruProtect. * Tick this box if you do NOT wish your Financial Adviser to act on your behalf to make changes or start the Plan I/We consent to PruProtect seeking details of the mortgage from the lender. I/We am/are aware that the income benefits I/we receive could affect the amount of any income support/income based Jobseekers Allowance, should I/We be eligible for state help. General information 1.By returning this form to us you consent to our processing sensitive personal data about you where this is necessary. 2.Copies of the plan provisions, and the completed application form are available on request. 3.If anyone else fills in this Application on your behalf, He/She does so as your agent and not as an agent of PruProtect. He/She does not have the authority to accept this Application on behalf of PruProtect. 4.Completion of the direct debit instruction does NOT imply commencement of your plan assurance risk. PruProtect’s letter of acceptance will indicate when the plan will commence. In most instances your payments will be as originally quoted. Revised terms may be offered to you, for example if you have a birthday while your application is being processed but occasionally we may be unable to offer any terms. 5.The direct debit instruction attached is designed to enable you to pay premiums to PruProtect with the minimum of inconvenience as and when they fall due. If the amount payable under your instruction is due to be altered, PruProtect will advise you of details of the new amount shortly before your account is due for debiting. Direct debits under this Instruction will be originated only in respect of premiums payable in accordance with the terms of the plan for which it is drawn 6.If the Applicant is not the life or lives to be assured, you must have sufficient insurable interest to be able to apply for the plan on this basis. If in doubt, please check with your financial adviser that sufficient insurable interest exists. We think it’s important for all our customers to be made aware of what information PruProtect as part of the PruHealth Group* holds about them and to reassure our customers that we comply with the Data Protection Act 1998. How we use your personal information PruProtect will use your personal information (including information provided about your dependants) to underwrite, administer, profile your purchase preference and service your plan. By taking out a plan with us, you consent to us using your personal information and sensitive personal information (e.g. health information). We will also use your information for statistical data analysis, management information and fraud prevention purposes. Who we may give personal information to We may disclose your personal information to other companies in the PruHealth Group, our business associates, agents or service providers for the purposes above. Your information may be used by service providers in a country outside the European economic area, which may not have the same standard of data protection as in the UK. We will ensure appropriate safeguards are in place to protect your information. We will pass your personal information and information about your plan to any legal or regulatory body if required to do so. We may also use your information or give it to others, for research, statistical purposes or to improve our services, but we will remove your name and address from this first. We may send copies of correspondence relating to your plan to your financial adviser, if you’ve appointed one. We may provide information about a claim to them, although no medical information will be provided without your consent. When giving us information about another person, you confirm that they have appointed you to act on their behalf. This includes providing consent to process the personal information, receive this data protection notice on their behalf and unless you decide otherwise, receive marketing information. Your information, and that of others also covered by the plan, may be given to other parties (for example, other insurance companies) with a view to preventing fraudulent or improper claims. Our marketing policy and opting out from future marketing PruProtect, PruHealth’s group of companies and our business associates, service providers and agents would like to use your personal information to inform you of other services and products that may be of interest to you by telephone, post, email or text. You can exercise your right to opt out of future marketing campaigns by choosing one or all of the opt out options below. If you choose not to opt out of future marketing right now, you may chose to opt out at any point during the life of your policy by contacting our customer services department or by sending us an email at [email protected]. You have the right to request a copy of the information we hold about you or someone you act on behalf of (for which we may charge a fee) and to have any inaccurate information corrected by writing to the data protection co-ordinator at the below address: PruHealth / PruProtect, Marshall Point, 4 Richmond Gardens, Bournemouth, BH1 1JD Disposal of information We will continue to hold information about you and your Plan for a reasonable period of time after it has ended. We will then dispose of your personal information in a responsible way to maintain your confidentiality. 25 IMPORTANT: Please complete this section with your client(s) if you are using this document as a full paper application form Declaration Changing this Data Protection Notice This Data Protection Notice may change from time to time and you should review the contents regularly. We will notify you of any changes where we are required to do so by law. * PruHealth is a joint venture between Prudential in the UK and Discovery Holdings Limited in South Africa. The PruHealth Group includes Prudential Health Limited and Prudential Health Insurance Limited, both trading as PruHealth, and Prudential Health Services Limited trading as PruHealth and/or PruProtect. I/We have read the information relating to My/Our rights under the Data Protection Act, the declaration, important notes and general information. Signature of Life Assured Signature Date D D M M Y Y Y Y Date D D M M Y Y Y Y Signature of applicant if different Signature 26 Next steps in the application process If submitting your client’s application online at pruprotect.co.uk 1) Detach the Access to Medical Reports Act form on pages 23-24 and return to us as indicated. 2) Once you have entered all details online you will be prompted to: a)Print off a copy of the client underwriting brochure and hand it to your client so they are aware of the next steps in the application process b) If you have not done so already, print off the Access to Medical Reports Act form and obtain your client’s signature on it. Please post the form to PruProtect, Customer Services, New Business, Stirling FK9 4UE or fax to 0870 240 0937 c) If you have not already inputted the details online, print off the direct debit instructions form and obtain your client’s signature. Please post the form to PruProtect, Customer Services, New Business, Stirling FK9 4UE or fax to 0870 240 0937 3)In the event that you find any errors or omissions, please call us and let us know on 0845 601 0072 or you can notify us in writing on the form, at the end of the confirmation schedule. If you are happy that the information in the confirmation schedule is complete and correct you do not need to do anything further. 4)Many applications can be approved without further underwriting. However if further underwriting is required your client will be issued a letter keeping them informed of the progress of their application. 5)Once we have reached our underwriting decision your client will receive an acceptance letter. In some instances where special terms have been offered we will need the client’s signature before we can proceed. 6)Your client will receive a welcome pack including a policy schedule, policy summary and plan provisions plus details about Vitality and how they can log on to the Member Zone. USEFUL TIP: You can track all applications at the various stages of the new business and underwriting process on the Intermediary Zone, as well as view those that have gone on risk. To sign up to email alerts simply log on to the old Quote and Apply system by navigating to right hand side of the new quote and apply system dashboard and using the links under the ‘Useful links’ section, select ‘Application alerts and communication preferences’ in the left hand navigation, then Application status updates’ and add your email address. 27 Notes 28 Notes 29 Notes 30 Notes 31 pruprotect.co.uk PruProtect is a trading name of Prudential Health Services Limited. Prudential is a trading name of The Prudential Assurance Company Limited. The Prudential Assurance Company Limited, registration number 00015454 is the insurer that underwrites the PruProtect plan. Prudential Health Services Limited, registration number 05933141 arranges and administers PruProtect plans underwritten by The Prudential Assurance Company Limited. Registered offices at Laurence Pountney Hill, London EC4R 0HH. Registered in England and Wales. Prudential Health Services Limited is authorised and regulated by the Financial Conduct Authority. The Prudential Assurance Company Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. PRUPF11353 09/2013