Flexible Protection Plan Personal Cover
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Suitable for use with our online application system Flexible Protection Plan Personal Cover Application Form This application form is for new Flexible Protection Plans only. If you already have a Flexible Protection Plan, and wish to add policies to it, or change the policies in it, please contact us for the appropriate application form. Important information Please bear in mind that we’ll share the information you give us in this application form with the other people involved in this application. Please be aware that we may not pay a claim and could cancel your policies if you don’t answer the questions in this application form truthfully and accurately. Data protection notice Your financial adviser may use information provided in this application form to process your application and to manage your plan. The information may be kept electronically or on, paper file for as long as the application is being considered, while the plan is active and for an appropriate period after that. Help us to help you… We aim to process your application as quickly as possible. However, to avoid unnecessary delay please make sure you read the important information shown below: Fully complete all sections in clear BLOCK CAPITALS and in black ink. Read, sign and date the declaration and complete the Direct Debit details. If you are applying for this plan with someone else you will both become the policy owners of every policy in the plan even if you are not the person insured. Where there are two policy owners, all correspondence will be addressed to both of you and sent to the address shown for the first policy owner. Medical correspondence will always be sent to the relevant person insured. Throughout this form ‘applicant’ means the person or people applying for the insurance, and will be the policy owners. ‘Person or people insured’ means the person or people you are insuring. If you are applying to insure your own life and/or health you need to complete all relevant sections. Online applications This application form can be used for both paper applications or as a data capture form for an online application. If you are using as a data capture form please read the information below that relates to online applications. Application types explained: Short form - To complete a short form application we only require basic information such as personal and product details including occupation questions. We’ll tell you in this form when you can stop. Once submitted the application will be passed to our Telephone Underwriting team to contact the client to complete the application in full. Normal form - To complete a normal form application we require full information to be entered online enabling us to make an instant decision. In many cases immediate acceptance is available. If the application is not accepted immediately it may be referred to our underwriters for individual consideration. Please note: When completing a normal form application if any of the questions on pages 20 to 22 are answered ‘yes’ please complete ‘details of specific medical condition’ on pages 25 to 28 for each disclosure. The ‘details of specific medical condition’ have been developed to capture as much information as possible to answer the active questions online, which cannot be completely duplicated in a paper format, as they are dependent upon the response. Your financial adviser will hold this information for the online application process. Once the application has been submitted to LV= by your financial adviser an application summary will be sent to you for your signature. 2 Which policies would you like to apply for: 1st Person Insured 2nd Person Insured Joint Life Life insurance Combined Life and Critical Illness cover Income Protection Personal Sick Pay Waiver of Premium Step 1 - About you Personal details of the person or people being insured Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following sections truthfully and accurately. 1st person insured 2nd person insured (if applicable) Title Title Mr/Mrs/Miss/Ms/Dr/Other Mr/Mrs/Miss/Ms/Dr/Other First name(s) First name(s) Surname Surname Maiden name (if applicable) Maiden name (if applicable) Date of birth / Gender / (DD/MM/YYYY) Male Female Date of birth / Gender / (DD/MM/YYYY) Male Telephone number (including area code) Telephone number (including area code) Day Day Evening Evening House number or name House number or name Address Address Postcode Postcode Country Country Email address Email address Flexible Protection Plan Personal Cover Female Application Form 3 Questions regarding the person or people insured 1st person insured Do you have existing Life, Income Protection, Personal Sick Pay or Critical Illness policies with, LV= or Liverpool Victoria? Yes 2nd person insured (if applicable) No Yes No If ‘yes’ please supply your existing policy number(s) if known. How much cover do you have with LV= or Liverpool Victoria? £ £ Will you be cancelling any of these policies? Yes No Yes No Are you an existing member of Liverpool Victoria Friendly Society Limited? Yes No Yes No If ‘no’ please complete the ‘Details of Applicant(s)’ section. Yes No Yes No Have you any prospect or intention of residing outside the UK? Yes No Yes No If ‘yes’, please supply your existing policy number(s) (if known) Will the person insured also be the applicant? If ‘yes’ please give full details, including the proposed country of residence, how long you intend to live there and the month and year you intend to return to the UK. 1st person insured 2nd person insured (if applicable) 4 Details of applicant(s) This section should be completed only if the applicant(s) is/are different from the person or people being insured. Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. 1st applicant 2nd applicant (if applicable) Title Title Mr/Mrs/Miss/Ms/Dr/Other Mr/Mrs/Miss/Ms/Dr/Other First name(s) First name(s) Surname Surname House number or name House number or name Address Address Postcode Postcode Country Country If you are completing this form on behalf of a company or other body, please complete the following 2 questions. Full name of the company or other body? Client type Trustee Creditor Charity Estate Will Other 1st applicant Have you any prospect or intention of residing outside the UK? Yes 2nd applicant (if applicable) No Yes No If ‘yes’ please give full details, including the proposed country of residence, how long you intend to live there and the month and year you intend to return to the UK. 1st applicant 2nd applicant (if applicable) Flexible Protection Plan Personal Cover Application Form 5 1st applicant Do you have any existing Life, Income Protection, Personal Sick Pay or Critical Illness policies with LV= or Liverpool Victoria? 2nd applicant (if applicable) Yes No Yes No Yes No Yes No If ‘yes’ please supply your existing policy numbers (if known) Are you an existing member of Liverpool Victoria Friendly Society Limited? Insurable interest in the person or people being insured (reason you would lose out financially). If ‘other’ please give details 1st applicant 2nd applicant (if applicable) 6 Spouse Spouse Civil partner Civil partner Live-in partner Live-in partner Joint mortgage Joint mortgage Inheritance tax planning Inheritance tax planning Financial relationship Financial relationship Other Other Cover start date If your application is accepted on normal terms do you wish the policy to start immediately? Yes If ‘no’, please state the date you would like the policy to start. (DD/MM/YYYY) / / No Personal details of the person or people being insured (continued) Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following sections truthfully and accurately. 1st person insured Marital status Married Married Civil partner Civil partner Single Single Widowed Widowed Divorced/dissolution Divorced/dissolution Separated Separated ft What is your height? ins cms or What is your typical consumption of alcohol a week? 1 glass of wine (175ml) = 2 units, 1 pint of standard lager/beer = 2 units, 1 measure spirits (25ml) = 1 unit st Yes For the following tobacco products, please state your typical consumption a day. units a week No Yes No Cigarettes Cigarettes Cigars Cigars Pipe tobacco Pipe tobacco ounces or lbs kgs or units a week Have you smoked or used any tobacco or nicotine products in the last 12 months? Note: If you answer ‘no’ to this question, you may be asked to undergo a test to verify your answer. ins cms lbs kgs or ft or st What is your weight? 2nd person insured (if applicable) grams ounces or Flexible Protection Plan Personal Cover grams Application Form 7 Occupation details What is your occupation? 1st person insured 2nd person insured (if applicable) 1st person insured 2nd person insured (if applicable) Is your occupation admin/clerical and 100% office based? Yes No Yes No Does your job involve any manual work (for example: carrying, lifting, working with machinery or tools or working at heights or underground)? Yes No Yes No If ‘yes’, please give full details relating to your occupation including a description of your duties and percentage of time spent on each activity. 1st person insured 2nd person insured (if applicable) 1st person insured If your job involves driving (other than commuting to and from work) what is your annual business mileage? Do you have more than one occupation? 2nd person insured (if applicable) miles Yes miles No Yes No If ‘yes’, please provide details. 1st person insured 2nd person insured (if applicable) 1st person insured Does your job involve the following: armed forces (including reservists/territorial army), heights over 12 metres, overseas travel, oil/gas industry (offshore), aviation with flying duties, fishing, explosives, underwater work? Yes No 2nd person insured (if applicable) Yes No If you have answered ‘yes’ to the above question, please provide full details in the space provided below. If your job involves overseas travel please give full details of the countries, regions and cities you will visit, duration of stay, how many trips you make, and your duties while you are overseas. 1st person insured 2nd person insured (if applicable) 8 Step 2 - Cover details Cover details - personal cover Type of application Online short form Commission type Standard Online normal form Paper Life insurance 1st person insured and/or single cover Who is being insured? 2nd person insured and/or single cover Joint life both people first event Level amount of cover years Policy term Amount of cover £ years years £ £ Decreasing amount of cover Policy term Amount of cover years £ years £ years £ Inflation-linked amount of cover Policy term Amount of cover years £ years £ years £ Flexible Protection Plan Personal Cover Application Form 9 Combined Life and Critical Illness cover *For Guaranteed Premiums, the amount of the critical illness cover cannot be more than the amount of life cover. Important notes: You can choose to include or exclude total permanent disability, but the choice you make will apply to both people being insured for all combined life and critical illness policies in this plan. † Who is being insured? 1st person insured and/or single cover 2nd person insured and/or single cover Joint life both people first event Guaranteed or Guaranteed or Guaranteed or Reviewable Reviewable Reviewable Level amount of cover Type of premium* Policy term years years years Amount of life cover £ £ £ Amount of critical illness cover £ £ £ Total permanent disability† None None None Included Included Included Guaranteed or Guaranteed or Guaranteed or Reviewable Reviewable Reviewable Decreasing amount of cover Type of premium* Policy term years years Amount of life cover £ £ £ Amount of critical illness cover £ £ £ Total permanent disability† 10 years None None None Included Included Included Who is being insured? 1st person insured and/or single cover 2nd person insured and/or single cover Joint life both people first event Guaranteed or Guaranteed or Guaranteed or Reviewable Reviewable Reviewable Inflation-linked amount of cover Type of premium* Policy term years years years Amount of life cover £ £ £ Amount of critical illness cover £ £ £ Total permanent disability† None None None Included Included Included Income Protection Who is being insured? Depending on your circumstances you may need more than one Income Protection policy within your plan. Should you wish to effect two policies at the same time, you can do this by completing both columns for the person insured below. This policy is designed to pay a regular monthly income if you are unable to work because of sickness or accident. The payments from this policy are limited to 55% of income. When calculating this figure, all other sickness and accident insurances will be taken into account. It is important to check that the amount of cover for this policy (and all other sickness and accident policies) does not exceed 55% of earned income. Type of cover (i)* or 1st Person Insured 1st Person Insured 2nd Person Insured 2nd Person Insured Full Full Full Full Budget or Level Type of cover (ii)* or Index-linked or Reviewable or Level or Guaranteed Type of Premium Budget Index-linked or Index-linked Level or Reviewable Index-linked or Guaranteed Reviewable Budget or Level Guaranteed or Budget Guaranteed or Flexible Protection Plan Personal Cover Reviewable Application Form 11 1st Person Insured Age at which policy ends (This must be from age 50 to 70 inclusive). Amount of cover** (a month) Waiting period (months) 1st Person Insured years years £ £ 2nd Person Insured 2nd Person Insured years £ years £ 1 2 1 2 1 2 1 2 3 6 3 6 3 6 3 6 12 12 12 12 If you choose to include Waiver of premium the waiting period for waiver will match the shortest waiting period for your Income Protection/Personal Sick Pay cover, with a minimum waiting period of 1 month and up to a maximum of 6 months. If you have also chosen to include Life cover or Life with earlier Critical illness cover, then the waiting period for waiver will automatically match the one you have chosen for your Income Protection/Personal Sick Pay cover. * Please refer to your Policy Summary or Key Features document for a full explanation of types of cover ** The overall maximum amount of cover will be 55% of earned income LESS any payments from other sickness or accident insurance policies LESS 60% of any ill-health or retirement benefits LESS 60% of any continuing earnings from employment 12 Annual taxable earned income*** on which the Income Protection policy will be based: 1st Person Insured 2nd Person Insured (if applicable) Salaried employee - salary (not a company director) £ a year £ a year Salaried employee - salary (company director) £ a year £ a year Salaried employee - dividends (company director) £ a year £ a year Self-employed (Please indicate if your income arises from different sources. Separate policies will be issued to cover each source.) £ a year £ a year For how long will you receive full pay if you are off work because of sickness or accident? Would you receive reduced pay? If ‘Yes’, please state the period you would receive reduced pay and the percentage this will be of your full pay. months Yes months No Yes No period % period % *** By earned income, we mean the current income earned before tax, less any expenses that are allowable against income tax. Normally, if employed this will be your salary before tax, but for company directors, earned income may include earnings received as dividends provided these are paid from current profits. For self-employed individuals, earned income is taken to be their share of the profits, (gross profit less expenses). In the event of a claim we may request evidence of earnings such as most recent P60 and payslips for an employee, or the most recent accounts and HM Revenue & Customs notice of assessment for the selfemployed. We use this evidence to confirm the level of income before the claim, because it is this amount that we use to work out how much we’ll pay out. If the evidence we receive doesn’t support the amount of cover applied for, then the amount we’ll pay out for a claim may be less than the amount covered. More information on how we work out how much we can pay out is explained in the policy conditions. Flexible Protection Plan Personal Cover Application Form 13 Personal Sick Pay Who is being insured? Depending on your circumstances you may need more than one Personal Sick Pay policy within your plan. Should you wish to effect two policies at the same time, you can do this by completing both columns for the person insured below. This policy is designed to replace your income if you are unable to work due to sickness or accident. The amount you choose to insure should normally be no more than 60% of your income. We have a guarantee in place to protect the amount we will pay you for the first 2 years of a claim. This is explained in our full terms and conditions. To take out Personal Sick Pay, you must be able to answer yes to the following questions: 1st Person Insured 2nd Person Insured (if applicable) Are you resident in the UK and have been for the last two years? Yes No Yes No Are you registered with a UK General Practitioner (Doctor) and have been for the last two years? Yes No Yes No Type of cover (i)* 1st Person Insured 1st Person Insured 2nd Person Insured 2nd Person Insured Full Full Full Full Budget or Level Type of cover (ii)* Guaranteed Type of Premium Reviewable or Age at which policy ends (This must be from age 50 to 70 inclusive). Amount of cover** (a month) Waiting period (weeks) Guaranteed Reviewable or years Reviewable or Index-linked or Guaranteed years £ £ Level Index-linked or Budget or Level Index-linked or Budget or Level Index-linked or Budget or Guaranteed Reviewable or years £ years £ Day one option Day one option Day one option Day one option 1 4 1 4 1 4 1 4 8 13 8 13 8 13 8 13 26 52 26 52 26 52 26 52 * Please refer to your Policy Summary, Key Features document, or Policy Conditions document for a full explanation of types of cover ** The overall maximum amount of cover should normally be 60% of current earned income 14 If you choose to include Waiver of premium the waiting period for waiver will match the shortest waiting period for your Income Protection/Personal Sick Pay cover, with a minimum waiting period of 1 month and up to a maximum of 6 months. If you have also chosen to include Life cover or Life with earlier Critical illness cover, then the waiting period for waiver will automatically match the one you have chosen for your Income Protection/Personal Sick Pay cover. 1st Person Insured Yes Do you currently work 30 hours or more each week? 2nd Person Insured (if applicable) No Yes No Annual taxable earned income*** on which the Personal Sick Pay policy will be based: Salary Salary Salaried employee a year £ a year Salary Salary Salaried employee (not a company director) £ a year £ Salary £ a year Salary a year £ Dividends a year £ Dividends Salaried employee (company director) £ a year £ a year Self-employed (Please indicate if your income arises from different sources. Separate policies will be issued to cover each source.) £ a year £ a year For how long will you receive full pay if you are off work because of sickness or accident? Would you receive reduced pay? If ‘Yes’, please state the period you would receive reduced pay and the percentage this will be of your full pay. months Yes months No Yes No period % period % *** By earned income, we mean the current income earned before tax, less any expenses that are allowable against income tax. Normally, if employed this will be your salary before tax, but for company directors, earned income may include earnings received as dividends provided these are paid from current profits. For self-employed individuals, earned income is taken to be their share of the profits, (gross profit less expenses). In the event of a claim we may request evidence of earnings such as most recent P60 and payslips for an employee, or the most recent accounts and HM Revenue & Customs notice of assessment for the selfemployed. We use this evidence to confirm the level of income before the claim, because it is this amount that we use to work out how much we’ll pay out. If the evidence we receive doesn’t support the amount of cover applied for, then the amount we’ll pay out for a claim may be less than the amount covered. More information on how we work out how much we can pay out is explained in the policy conditions. Flexible Protection Plan Personal Cover Application Form 15 Waiver of Premium 1st person insured Do you require Waiver of Premium? Yes No 2nd person insured (if applicable) Yes No If you choose to include Waiver of Premium with your Life or Combined Life and Critical Illness cover, we will assume a 6 month waiting period. If you have chosen to include Income Protection or Personal Sick pay the waiting period for waiver will match the shortest waiting period for that cover, with a minimum waiting period of 1 month and up to a maximum of 6 months. 16 Step 3 - Risk assessment If you are completing an online short form application please continue on page 24. For a normal application, and for all paper based applications, please complete the following sections in full. Lifestyle and leisure pursuits of the person or people being insured Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. 1st person insured 2nd person insured (if applicable) Do you have any intention of going abroad for longer than 30 days? Yes No Yes No If ‘yes’ do you only travel to Europe, North America, Australia, New Zealand, Singapore, Hong Kong, Japan, United Arab Emirates or China? Yes No Yes No If ‘no’, please give full details of the countries, regions and cities you will visit, duration of stay, how many trips you make, and the reasons for the trip(s). 1st person insured 2nd person insured (if applicable) 1st person insured Within the last 5 years have you lived or frequently travelled to an area which has a high incidence of HIV infection? Yes No 2nd person insured (if applicable) Yes No If ‘yes’ please give full details of countries visited, dates, duration and any future plans 1st person insured 2nd person insured (if applicable) Flexible Protection Plan Personal Cover Application Form 17 1st person insured Including this application, will the total amount of cover on your life exceed £1m life insurance, £500,000 critical illness cover or £150,000 sickness cover (you can ignore cover that is being cancelled or multiple applications where only one will proceed)? Yes 2nd person insured (if applicable) No Yes No If ‘no’ go to the hobbies section on page 19. If ‘yes’ please answer the following questions: Please give full details of all existing policies: 1st or 2nd person insured Name of company Type of policy Amount of cover / term Reason for cover Is this cover being cancelled and/or replaced? For life and critical illness: Please state your current annual taxable income (if applicable this can include bonuses, regular commission and the value of any benefits) 1st person insured 2nd person insured (if applicable) £ £ You only need to answer the remaining questions on this page if the total amount of life insurance with LV= will be between £1.5m - £2.5m. Please advise the reason for cover? For family protection cover please give details of the number and age of dependants and their relationship to you: For mortgage protection cover, please confirm the amount and term of the mortgage and the mortgage lender: For all other types of cover, please provide full details regarding the requested amount of cover and how this amount has been calculated: 18 Hobbies 1st person insured Do you intend to take part in any physical hobby or sport (for example motor sport, mountaineering, diving, combat sports, horse riding, mountain biking, aviation, rugby or football)? Yes No 2nd person insured (if applicable) Yes No If ‘yes’ please give full details 1st person insured 2nd person insured (if applicable) Medical details of the person or people being insured Genetic test results For this application we do not need to know about any genetic test result subject to the amount of cover being within: -- £500,000 or less for Life Protection -- £300,000 or less for Critical Illness -- £30,000 or less for Income Protection or Personal Sick Pay. Above these limits, you may need to tell us about certain genetic test results. We will only be interested in genetic test results where the Government’s Genetics and Insurance Committee has approved them for insurers to use. If you think this may apply to you, please ask us for details of the current position. In all cases you must tell us if you are experiencing symptoms of, or having treatment for a genetic condition. However, for a genetic condition present in the immediate family, it will be worthwhile to tell us of a negative test for the same condition. Details of the Association of British Insurer’s Code of Practice in relation to genetic testing and insurance are available on request. Flexible Protection Plan Personal Cover Application Form 19 Medical details of the person or people being insured Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. If any of the following questions are answered ‘yes’ you will need to complete the additional medical questions on pages 25 to 28. 1st person insured 2nd person insured (if applicable) 1a) Have you ever tested positive for HIV, Hepatitis B or C? Yes No Yes No 1b) Have you ever used recreational drugs (e.g. cannabis, cocaine, heroin) Yes No Yes No 2) Do you currently have or have you ever had any of the following: 2a) Diabetes or sugar in the urine? Yes No Yes No 2b) Heart condition including heart attack, angina, heart valve disorder or heart enlargement? Yes No Yes No 2c) A vascular or circulatory condition including stroke, Transient Ischaemic Attack (TIA), brain haemorrhage or narrowing or obstruction in the arteries? Yes No Yes No 2d) Cancer, tumour, leukaemia, Hodgkin’s disease or lymphoma? Yes No Yes No 2e) Any condition of the central nervous system (the brain, spinal cord and nerves) including multiple sclerosis, optic neuritis, Parkinson’s disease, paralysis, Alzheimer’s disease, dementia or cerebral palsy? Yes No Yes No 2f) Mental health issue that has resulted in referral to a psychiatrist, required hospital treatment or any episode of suicide attempt, suicidal thoughts or self harm? Yes No Yes No 3) In the last 5 years have you had any of the following: (This is regardless of whether or not you have seen your doctor or required treatment.) 20 3a) Raised blood pressure, raised cholesterol, chest pain or irregular heart beat? Yes No Yes No 3b) A mole or freckle that has bled, become painful, changed appearance or any lump or growth? Yes No Yes No 3c) Asthma, bronchitis or any other respiratory condition? Yes No Yes No 3d) Any joint, bone or muscle pain, fracture, gout or arthritis? Yes No Yes No 1st person insured 2nd person insured (if applicable) 3e) Any back or neck condition, including pain, sciatica or whiplash? Yes No Yes No 3f) Mental health issue including depression, anxiety, stress, nervous breakdown, insomnia, or eating disorders? Yes No Yes No 3g) Chronic Fatigue Syndrome (CFS), ME, or fibromyalgia? Yes No Yes No 3h) Any digestive, liver, stomach, pancreas or bowel condition including ulcer, hepatitis, colitis or Crohn’s disease? Yes No Yes No 3i) Kidney, bladder or urinary condition including blood or protein in the urine and urinary tract infection? Yes No Yes No 3j) Seizure, fits, epilepsy, fainting, dizziness, tremor, blackouts, facial pain or migraines? Yes No Yes No 3k) Numbness, change in skin sensation, lack of coordination, difficulty walking or temporary loss of muscle power? Yes No Yes No 3l) Any eye condition including eye pain, blurred or double vision? (Sight problems corrected by glasses or contact lenses can be ignored.) Yes No Yes No 3m)Any ear, hearing or balance condition? Yes No Yes No 3n) Any cervical smear or other gynaecological condition needing treatment, investigation or advice? Yes No Yes No 3o) Prostate enlargement or abnormalities? Yes No Yes No 3p) Blood disorder or anaemia? Yes No Yes No 4a) In the last 5 years have you had any medical attention at a hospital or required any investigations, scans or tests (including blood tests), in connection with any medical condition which you haven’t told us about already in this application form? Yes No Yes No 4b) Do you have another medical condition, which you haven’t told us about already in this application, for which you are taking prescribed drugs, medicines, tablets or any other treatment? (Please ignore contraceptives, HRT, hayfever treatments, cold/ flu remedies) Yes No Yes No 4c) Are you awaiting the results of, or have you been advised to have, any medical investigations, tests or scans or have you any expectation of seeking medical advice or treatment in the near future? Yes No Yes No Flexible Protection Plan Personal Cover Application Form 21 1st person insured 2nd person insured (if applicable) 5) Have you ever been advised to reduce or stop drinking alcohol for a medical or health reason which you haven’t told us about already in this application form? Yes No Yes No 6) In the last 5 years have you drunk more than 30 units of alcohol a week on a regular basis? 1 glass of wine (175ml) = 2 units, 1 pint of standard lager/ beer = 2 units, 1 measure spirits (25ml) = 1 unit Yes No Yes No 7) Are you currently off work, working reduced hours or have you altered your duties due to sickness or injury? Yes No Yes No 8) In the last 2 years have you been off work due to sickness or injury for a period of 5 or more days in a row? Yes No Yes No If ‘yes’ please provide full details 1st person insured 2nd person insured (if applicable) If ‘yes’, please provide full details. 1st person insured 2nd person insured (if applicable) If any of the above questions are answered ‘yes’, you will need to complete the additional medical questions on pages 25 to 28. A new page should be completed for each medical condition. 22 Family history of the person or people being insured Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. 1st person insured Have any of your natural parents, brothers or sisters been diagnosed with or died from any of the following hereditary disorders before the age of 60? Yes 1st or 2nd person Relation insured? No 2nd person insured (if applicable) Yes Age at onset No Current age or age at death a) Heart disease, including heart attack, angina, by-pass or heart enlargement/cardiomyopathy? (please circle which condition was diagnosed) b)Stroke? c)Diabetes? d) Cancer? (please state the area affected) e) Multiple Sclerosis? f) Huntington’s disease? g) Polycystic kidney disease? h) Polyposis of the colon? i) Motor neurone disease? j) Parkinson’s disease? k) Alzheimers disease? l) Other hereditary disorders? Flexible Protection Plan Personal Cover Application Form 23 Doctor/clinic details of the person or people being insured You should not assume that we will write to your doctor for a report, although we may do so. 1st person insured 2nd person insured (if applicable) Name of doctor/clinic Name of doctor/clinic House number or name House number or name Surname Surname Address Address Postcode Postcode Telephone number (including area code) Telephone number (including area code) Telephone appointment for the person or people being insured We may need to contact you by telephone to gather some additional information. Please select the most convenient time and telephone number for us to call you. Every effort will be made to contact you during the selected time period. 1st person insured 9am - 12 noon Time 2nd person insured (if applicable) 12 noon - 6pm 6pm - 9pm Telephone number (including area code) 9am - 12 noon Time 12 noon - 6pm 6pm - 9pm Telephone number (including area code) Do you know of any dates in the near future when you will be unavailable for a telephone appointment? If ‘yes’, please provide details below 1st person insured 2nd person insured (if applicable) 24 Details of specific medical condition 1 This page is provided so that you can give us further information about any medical conditions that you have you have told us about in pages 20-22. Please complete a separate page for each medical condition, and continue on a blank sheet of paper if necessary. Detailed answers to these questions may help to speed up the processing of your application. Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. (Please be as specific as possible, if relevant please give specific details of the limb/part of the body involved. For example: arthritis – right knee; breast cyst) 1st person insured To which person insured does the following information apply? 2nd person insured Which question do the following answers relate to on pages 20-22? What condition has been diagnosed? When did this condition first occur? / (MM/YYYY) When did you last have symptoms? / (MM/YYYY) Have symptoms been continuous? Yes No Yes No Yes No Yes No Yes No Yes No If you’ve had time off work, have you now fully returned to work? Yes No Are you fully recovered? Yes No If ‘no’, how many episodes have you suffered? Please confirm what symptoms you are suffering or have suffered and the severity Have you been told that this condition is due to another medical condition? If ‘yes’, please provide full details. Are you currently having treatment, for example any medication or specialist appointments? If ‘yes’, please confirm the type of treatment being received and the frequency If you have had previous treatment, please confirm the type and the frequency Have you had any tests or investigations? If ‘yes’, what were they? What were the results? Have you been admitted to hospital with this condition? If ‘yes’, how many times? and when? Are you awaiting any investigations, operation or the results of tests or investigations? If ‘yes’, please provide details. How much time off work have you taken in relation to this condition and when was this? Flexible Protection Plan Personal Cover Application Form 25 Details of specific medical condition 2 This page is provided so that you can give us further information about any medical conditions that you have you have told us about in pages 20-22. Please complete a separate page for each medical condition, and continue on a blank sheet of paper if necessary. Detailed answers to these questions may help to speed up the processing of your application. Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. (Please be as specific as possible, if relevant please give specific details of the limb/part of the body involved. For example: arthritis – right knee; breast cyst) To which person insured does the following information apply? 1st person insured 2nd person insured Which question do the following answers relate to on pages 20-22? What condition has been diagnosed? When did this condition first occur? / (MM/YYYY) When did you last have symptoms? / (MM/YYYY) Have symptoms been continuous? Yes No Yes No Yes No Yes No Yes No Yes No If you’ve had time off work, have you now fully returned to work? Yes No Are you fully recovered? Yes No If ‘no’, how many episodes have you suffered? Please confirm what symptoms you are suffering or have suffered and the severity Have you been told that this condition is due to another medical condition? If ‘yes’, please provide full details. Are you currently having treatment, for example any medication or specialist appointments? If ‘yes’, please confirm the type of treatment being received and the frequency If you have had previous treatment, please confirm the type and the frequency Have you had any tests or investigations? If ‘yes’, what were they? What were the results? Have you been admitted to hospital with this condition? If ‘yes’, how many times? and when? Are you awaiting any investigations, operation or the results of tests or investigations? If ‘yes’, please provide details. How much time off work have you taken in relation to this condition and when was this? 26 Details of specific medical condition 3 This page is provided so that you can give us further information about any medical conditions that you have you have told us about in pages 20-22. Please complete a separate page for each medical condition, and continue on a blank sheet of paper if necessary. Detailed answers to these questions may help to speed up the processing of your application. Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. (Please be as specific as possible, if relevant please give specific details of the limb/part of the body involved. For example: arthritis – right knee; breast cyst) 1st person insured To which person insured does the following information apply? 2nd person insured Which question do the following answers relate to on pages 20-22? What condition has been diagnosed? When did this condition first occur? / (MM/YYYY) When did you last have symptoms? / (MM/YYYY) Have symptoms been continuous? Yes No Yes No Yes No Yes No Yes No Yes No If you’ve had time off work, have you now fully returned to work? Yes No Are you fully recovered? Yes No If ‘no’, how many episodes have you suffered? Please confirm what symptoms you are suffering or have suffered and the severity Have you been told that this condition is due to another medical condition? If ‘yes’, please provide full details. Are you currently having treatment, for example any medication or specialist appointments? If ‘yes’, please confirm the type of treatment being received and the frequency If you have had previous treatment, please confirm the type and the frequency Have you had any tests or investigations? If ‘yes’, what were they? What were the results? Have you been admitted to hospital with this condition? If ‘yes’, how many times? and when? Are you awaiting any investigations, operation or the results of tests or investigations? If ‘yes’, please provide details. How much time off work have you taken in relation to this condition and when was this? Flexible Protection Plan Personal Cover Application Form 27 Details of specific medical condition 4 This page is provided so that you can give us further information about any medical conditions that you have you have told us about in pages 20-22. Please complete a separate page for each medical condition, and continue on a blank sheet of paper if necessary. Detailed answers to these questions may help to speed up the processing of your application. Please be aware that we may not pay a claim and could cancel the policy if you do not answer the following questions truthfully and accurately. (Please be as specific as possible, if relevant please give specific details of the limb/part of the body involved. For example: arthritis – right knee; breast cyst) To which person insured does the following information apply? 1st person insured 2nd person insured Which question do the following answers relate to on pages 20-22? What condition has been diagnosed? When did this condition first occur? / (MM/YYYY) When did you last have symptoms? / (MM/YYYY) Have symptoms been continuous? Yes No Yes No Yes No Yes No Yes No Yes No If you’ve had time off work, have you now fully returned to work? Yes No Are you fully recovered? Yes No If ‘no’, how many episodes have you suffered? Please confirm what symptoms you are suffering or have suffered and the severity Have you been told that this condition is due to another medical condition? If ‘yes’, please provide full details. Are you currently having treatment, for example any medication or specialist appointments? If ‘yes’, please confirm the type of treatment being received and the frequency If you have had previous treatment, please confirm the type and the frequency Have you had any tests or investigations? If ‘yes’, what were they? What were the results? Have you been admitted to hospital with this condition? If ‘yes’, how many times? and when? Are you awaiting any investigations, operation or the results of tests or investigations? If ‘yes’, please provide details. How much time off work have you taken in relation to this condition and when was this? 28 Important notes The plan will start on the start date shown in your policy schedule. If you have a birthday while your application is being processed, the terms may differ from those originally quoted to you. Also after we’ve processed your application we may have to offer you revised terms, and occasionally we may not be able to offer any terms. We may ask you to contact your doctor if we’re waiting for reports which we’ve asked for. If we ask you to come for a medical examination, we’ll need to share the application information with another company we’ve authorised. They will make the arrangements for the examination to take place. We may need to send your application and relevant medical reports to our reinsurers for their opinion or agreement of the terms offered. Or, we may need to send them at a later stage for purposes relating to managing the policies in your plan. You can get details of general reassurance principles and details of any company we use to assess your application, from our Head Office. We have a confidentiality policy in place which means we hold your medical information securely and access is limited to authorised individuals who need to see it. You’re entitled to ask for a copy of our standard terms and conditions and a copy of your application form at any time. Access to medical reports We may need to get medical reports to support your application. Before we can ask any doctor that you’ve consulted to fill in a report, we need your permission under the Access to Medical Reports Act 1988 (AMRA). Your rights under the act are as follows. You don’t need to give your permission, but if you don’t, we may not be able to go ahead with your application. This doesn’t prevent you from applying to other companies for insurance. You can ask to see the report before the doctor returns it to us. If this is the case, we’ll tell the doctor to keep the report for 21 days so that you can arrange to see it. If you haven’t 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 change it. If your doctor refuses to make the changes, you may ask them to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report if they feel 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’re currently receiving. -- the results of referrals or tests you’re 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; •musculoskeletal disease or injury, for example, arthritis, rheumatism, back problems or any other disorder of the joints or muscles; •anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose 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’ve told your doctor about. Flexible Protection Plan Personal Cover Application Form 29 We’ve 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: LV=, Pynes Hill House, Rydon Lane, Exeter EX2 5SP You should not assume that we’ll write to your doctor for a report, although we may do so. Please ensure that you answer all the questions truthfully and accurately. You MUST tell us of any changes in your health, occupation duties or other information provided in this application which take place before any of the policies you’ve applied for start. For example you must tell us if you’ve had any medical consultations, advice, treatment, or investigations, or if you’ve changed job, or the main duties that you carry out as part of your job have changed. If you don’t tell us, we may not pay a claim, and could cancel the policies in your plan. Please be aware that we may not pay a claim, and could cancel your policies if you do not answer all of the questions in this application truthfully and accurately. Whilst the vast majority of our customers are honest we do have to protect ourselves (and all of our customers) against the effect of fraudulent claims. As part of our ongoing quality control process we continually monitor all completed applications to help ensure that the information provided is correct, and that people haven’t deliberately provided us with false or misleading information. We do this by reviewing a random sample of applications to ensure that the policies were correctly underwritten by us, and that we have received all of the information we asked for during the application process. If your application is selected, we will write to your general practitioner (GP) to ask for a medical report. We’ll use this Declaration you sign to authorise us to contact your GP. The important notes in this application explain your rights under the Access to Medical Reports Act 1988 (AMRA). 30 Declaration I agree to Liverpool Victoria Friendly Society Limited (LV=) asking any doctor I have consulted about my physical or mental health to provide medical information so LV= may assess my application. LV= may gather relevant information from other insurers about any other applications for life, critical illness, sickness, disability, accident or private medical insurance that I have applied for. I authorise those asked to provide medical information when they see a copy of this consent form. This declaration allows LV= to gather medical reports within six months of the start of the plan, or after my death, to support any claim made on the plan proceeds. This information can also be used to maintain management information for business analysis. By signing this declaration I am allowing LV= to process my application using the information that I have given. LV= may also use this information to process any claims made on the policies I have applied for. I am aware that all the people involved in this application must sign this declaration. For the person or people insured, they must also sign the summary of any interviews that may be required for the purposes of underwriting the policies applied for. I wish to enter into a contract for the policies noted in this application on LV= normal terms and conditions. I hereby declare that my answers in this application are true and complete and that I haven’t knowingly withheld or concealed any information that LV= has asked for. I’m aware that if I have then my plan could be cancelled and that LV= may not pay a claim. I acknowledge that any policy which LV= may issue to me is based on the information in this application, the answers in my medical report(s), if any, and this declaration. I will tell LV= immediately of any changes in my health, occupational duties or other information provided to LV= that happen before the policies I have applied for start. I am aware that LV= must be told about these changes, and if I don’t tell LV= about them, I’m aware that my plan may be cancelled, and that a claim may not be paid. To the best of my knowledge and belief all the statements made, which includes anything I may have said, have been recorded accurately in this application or are attached in a sealed private and confidential envelope, and are true and complete. (Please tick if you have attached a private and confidential envelope ). I agree that LV= can use any sensitive information provided by me or on my behalf, such as health and medical information, to process my application, for business analysis purposes and for the ongoing management of my policies. This information may be passed on to: -- my GP -- any medical practitioner and/or health care professional acting for LV= -- reinsurers or any other insurer I’ve applied and given consent to -- my financial adviser -- any trustee or assignee of the policies (where a policy is assigned or placed in trust) -- any associated company of LV= I agree to LV= accepting medical reports faxed or emailed directly to LV= from my doctor’s surgery. I also do not object to copies of the report being faxed or emailed to any of those parties to whom LV= may disclose personal data, as stated above, at their request. In the event of a claim I am aware that my names, dates of birth and post code will be provided to the Association of British Insurers (ABI) Health Claims database which has been set up to deter/prevent fraud. LV= may use information given to make searches about me at credit reference agencies and other organisations that hold my information (such as from the electoral roll) to check my identity. The agencies and other organisations may keep records of these searches, even if my application doesn’t go ahead. LV= may use scoring methods to check my identity and may ask me for supporting documents. I confirm that I am a UK resident (excluding Channel Islands and Isle of Man). Flexible Protection Plan Personal Cover Application Form 31 I may be contacted by telephone, post or other electronic methods. LV= may use information provided to process my application and manage my plan. The information may be kept electronically or on paper file for as long as the application is being considered, while the policies applied for are active and for an appropriate length of time after that. To support LV= in underwriting your application, we may check any information you have provided about yourself and the business with other organisations that may hold this information. We will use this information to assist us in reaching an underwriting decision in a timely manner and where possible avoid the need for additional documentation from yourself. LV= will keep my information and add it their customer databases even if my application doesn’t go ahead. LV= may use it to keep their records up to date, for business analysis and market research. LV= won’t include you in direct marketing campaigns but we may pass your details to other carefully selected organisations, but only for the purposes listed here. Subject to the payment of a fee, if you’d like LV= to send you a copy of the personal information we hold about you, please write to: CCA Department, LV=, County Gates, Bournemouth, BH1 2NF. For more information about the LV= group of companies please go to www.LV.com. If false or inaccurate information is provided and fraud is identified, details will be passed to fraud prevention agencies to prevent fraud and money laundering. Further details explaining how the information held by fraud prevention agencies may be used can be obtained by writing to Group Financial Crime, LV=, County Gates, Bournemouth BH1 2NF. 1st person insured 2nd person insured (if applicable) I want to see the medical report before it is sent to LV= Yes No Yes No I agree to allow copies of the medical report to be faxed or emailed Yes No Yes No I confirm that I have read the important notes and declaration and information relating to my rights under the Access to Medical Reports Act Yes No Yes No I am aware that by signing below I agree to be bound by this declaration. 1st person insured signature Date 32 / 2nd person insured (if applicable) signature / (DD/MM/YYYY) Date / / (DD/MM/YYYY) 1st applicant if different from person insured signature 2nd applicant (if applicable) if different from person insured signature Date Date / / (DD/MM/YYYY) / / (DD/MM/YYYY) Step 4 - Payment details The Direct Debit Guarantee - To be retained by the applicant(s) 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 LV= will notify you 10 working days in advance of your account being debited or as otherwise agreed. If you request LV= 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 LV= 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 LV= 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. Direct Debit is a simple method of payment and is required in all cases. The instruction conforms to the strict requirements of the clearing banks and you are fully protected by the safeguards under the Direct Debit Guarantee. We will give you advance notice of the payments and details of the guarantee when the risk has been accepted by the underwriter. The direct debit should be completed but not detached. Instruction to your Bank or Building Society to pay by Direct Debits Please fill in the whole form and send it to: LV=, Pynes Hill House, Rydon Lane, Exeter, EX2 5SP. Please ensure you complete all details 1. Name and full postal address of your Bank or Building Society Service user number To: The Manager Bank or Building Society 4. Bank or Building Society account No. Address 5. For completion by LV= 6. Instruction to your Bank or Building Society Please pay Liverpool Victoria Friendly Society Limited Direct Debits from the account detailed on this instruction subject to the safeguards assured by The Direct Debit Guarantee. I understand that this instruction may remain with Liverpool Victoria Friendly Society Limited and, if so, details will be passed electronically to my Bank/Building Society. Postcode 2. Name(s) of account holder(s) Signature Date 3. Branch sort code (from the top right hand corner of your cheque) – – Banks and Building Societies may not accept Direct Debit Instructions for some types of accounts. Flexible Protection Plan Personal Cover Application Form 33 This page is intentionally blank - your financial adviser will complete their details on the next page. 34 For financial adviser use only For paper applications Address for applications LV=, Pynes Hill House, Rydon Lane, Exeter EX2 5SP. Please tick the relevant boxes. All relevant sections filled in? Is a trust form included? Has the declaration been signed? Have you provided your agency details? Have the doctor’s details been fully completed? Have you attached the relevant illustration? Commission options (please tick your preferred option) Commission Sacrifice or nil commission is not supported for Personal Sick Pay Insurance Full initial commission ( indemnified Initial commission sacrifice of: non-indemnified) and renewal commission % ( indemnified non-indemnified) Nil commission Source code financial adviser stamp and/or agency no: For online applications Will you (the agent) be obtaining all necessary signatures from the client(s)? Yes No Is this application to be written in trust Yes No If ‘yes’ once the application has been submitted please forward the trust document clearly marked with the application reference number to LV=, Pynes Hill House, Rydon Lane Exeter, EX2 5SP Once the application has been submitted, an Application Reference number and Interview number will be provided. Please enter them below and if you contact us regarding this application please quote the reference numbers. Application reference number Interview number Flexible Protection Plan Personal Cover Application Form 35 You can get this and other documents from us in Braille or large print by contacting us. Liverpool Victoria Friendly Society Limited: County Gates Bournemouth BH1 2NF. LV= and Liverpool Victoria are registered trademarks of Liverpool Victoria Friendly Society Limited (LVFS) and LV= and LV= Liverpool Victoria are trading styles of the Liverpool Victoria group of companies. LVFS is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority, register number 110035. Registered address: County Gates, Bournemouth BH1 2NF. Phone: 01202 292333. 0008750-2016 07/2016
