Relevant Life Cover How Advisers can use this form • Application / Data Capture form

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
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