Employer Questionnaire
Group Income Protection
Employer’s Claim Form
The responsibility for the completion of this form is with the policyholder of the Scheme.
Please complete this form in BLOCK CAPITALS and black ink if completing by hand.
All the information you give us will be treated in strict confidence.
It’s important that you answer all the questions on this application form fully, truthfully and accurately. If you don’t answer all the questions fully,
truthfully and accurately this could affect how much we pay out for your claim and could mean we won’t pay the claim at all.
Section A
1) Employer details
Policy number
Claim number
Employer’s name
Employer’s correspondence
address
Postcode
Employer’s contact number
Contact email address
Name of individual
dealing with the claim
Job title
Who funds the premium for
the employee’s benefit?
2) Employee details
Employee’s name
Date of birth
D D M M Y Y Y Y
Employee’s address
Postcode
Employee’s home number
Employee’s mobile number
Employee’s position held
in the company
Length of time in this
position
1
Date employee joined company
D D M M Y Y Y Y
Date employee joined scheme
(if scheme previously with other insurer)
D D M M Y Y Y Y
Date employee joined Aviva
Group Income Protection scheme
D D M M Y Y Y Y
First date of absence
D D M M Y Y Y Y
Group Income Protection Claim Form Employer Questionnaire
3) Incapacity details
Nature of incapacity
Is the employee seeking legal compensation against a third party or the insured company,
in connection with the declared incapacity?
Yes
No
Yes
No
If yes, please give details
Has the employee worked since the date of incapacity?
If yes, please provide details
Duties undertaken
Dates
Hours
Salary
£
£
£
£
4) Occupational details
With reference to the requirements of the Equality Act, please confirm the following:
Is the employee’s job still available to them?
Yes
No
Have you discussed returning to work with your employee?
Yes
No
Yes
No
Have you considered any adaptations that could be made to assist the employee when they return to work?
Yes
No
Do you have access to an occupational health nurse or doctor?
Yes
No
Yes
No
If yes, please provide details
Could the employee return to their own job part-time if their health prevented them from working full-time?
What alternative jobs would be available for the employee to return to?
If yes, what involvement have occupational health had to date?
How do you keep in regular contact with the employee?
What medical or other information do you request regarding this employee whilst they are unable to work?
Have you requested that the employee attend a company medical examination?
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Group Income Protection Claim Form Employer Questionnaire
5) Financial
Is the employee to be maintained on the payroll?
No
Yes
If no, please state the reason you would remove them from the payroll, for example ill health early retirement, resignation, dismissal etc.
D D M M Y Y Y Y
What date will the payment of salary or wages to the employee cease?
What was the employee’s salary when absence commenced?
£
How many hours is your employee contracted to work each week?
What is their start time?
What is their finish time?
Is the employee’s contract temporary or permanent?
Temporary
If temporary, please provide the dates the contract starts and is due to end.
Permanent
Start
D D M M Y Y Y Y
End
D D M M Y Y Y Y
Do you provide the employee with Private Medical Insurance (PMI)?
Yes
No
Yes
No
Yes
No
If yes, who is the PMI provider?
If yes, is there a limit or exclusion(s) on the cover?
If yes, please give details
If the employee does benefit from PMI, is psychiatric care covered?
If pension contribution benefit is insured under the policy, please confirm the following. If not, please continue to section 6.
Type of pension scheme, for example Money Purchase,
Final Salary, Personal Pension or other.
If other, please provide details.
Basis of contribution
%
employer
%
employee
£
Company Pension
Scheme cease age
6) Additional Information
Please give details of any other information that you feel would help us in the fair and accurate assessment of this claim
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Group Income Protection Claim Form Employer Questionnaire
flat amount
Section B
What type of industry does your employee work in?
Does your employee have any other occupation either employed by yourselves or another employer?
Yes
No
If yes, please submit job descriptions for each one
In what environment does your employee work, for example office, factory, outdoors?
Are there any environmental conditions which aggravate your employee’s incapacity, for example dust, weather, chemicals? If so, please give details
What special skills, qualifications or experience are required?
Is a driving licence or any other type of licence necessary to perform you employee’s occupation(s)?
How many staff does your employee supervise?
What machines, equipment or tools does your employee use or operate in relation to their occupation?
Does your employee’s occupation involve travelling other than to and from work?
If yes, please give details
Yes
No
Yes
No
How many miles does your employee travel per week?
How many hours does your employee spend travelling per week?
What form of transport does your employee use?
Are there any unusual aspects regarding hours of work, for example shift work, weekend work, being ‘on call’?
If yes, please provide details
Please list all the duties involved in your employee’s main occupation and the percentage of their working day spent on each (please ensure the
percentage total equals 100%)
Please also include a copy of your employee’s job description
Duty
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Group Income Protection Claim Form Employer Questionnaire
% of day spent on duty
Does the incapacity prevent them from
carrying out this duty? (Yes or No)
Aviva will contact your employee directly to complete their part of the claim form. This will usually be done by telephone and then
issued to the employee to check and sign.
Declaration
I will notify Aviva Health UK Limited immediately if circumstances relevant to the claim alter in any way.
I agree to Aviva Health UK Limited using such methods as they consider necessary and reasonable in order for the validity of this claim to be
established.
To the best of my knowledge and belief, I confirm the information provided in this section of the claim form is correct and complete.
I consent to the monitoring/recording of any telephone calls made to or from Aviva (or third parties acting on its behalf).
On behalf of the company, I confirm consent to the computer and other processing (which may be in any part of the world) of personal and medical
details supplied in support of the claim, including the information in or with this claim form, by the Data Controllers and relevant third parties
(including our insurance intermediary) for the purposes of claims assessment and validation, fraud prevention, policy administration, service provision
and reinsurance.
Signature
Print name
Position in company
Telephone
Date
D D M M Y Y Y Y
Please now check you have completed ALL questions. Print off a copy if completed online (you may also wish to keep a copy for your
records), sign the form and return.
Aviva Health UK Limited. Registered in England Number 2464270. Registered Office 8 Surrey Street Norwich NR1 3NG.
Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Firm Reference Number 308139. www.aviva.co.uk/health
This insurance is underwritten by Aviva Life & Pensions UK Limited. Registered in England No 3253947.
2 Rougier Street, York, YO90 1UU. Authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number 185896. www.aviva.co.uk
Aviva Health UK Limited, Head Office: Chilworth House Hampshire Corporate Park Templars Way Eastleigh Hampshire SO53 3RY.
CMSG002 07/2014 © Aviva plc
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Group Income Protection Claim Form Employer Questionnaire
Section C – Bank Details for Benefit Payments
Policyholder name
Policy number
Claim number
Bank name
Sort code
–
–
Account number
Account name
Remittance advice
addressee
Remittance advice
address
Postcode
Signature of
authorised official
Name
Position held
Telephone
Date
D D M M Y Y Y Y
Aviva Health UK Limited. Registered in England Number 2464270. Registered Office 8 Surrey Street Norwich NR1 3NG.
Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Firm Reference Number 308139. www.aviva.co.uk/health
This insurance is underwritten by Aviva Life & Pensions UK Limited. Registered in England No 3253947.
2 Rougier Street, York, YO90 1UU. Authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number 185896. www.aviva.co.uk
Aviva Health UK Limited, Head Office: Chilworth House Hampshire Corporate Park Templars Way Eastleigh Hampshire SO53 3RY.
CMSG002 07/2014 © Aviva plc
7
Group Income Protection Claim Form Employer Questionnaire
Section D – Employer Consent Form
Policyholder
Policy number
Insured person
Please complete only one of the following parts.
Part A
I do not authorise Aviva, their agents and sub-contractors to discuss any aspects of the above numbered policy specific to the above named insured
person with the insured person.
Signature of the authorised official for policyholder/employer
Date
D D M M Y Y Y Y
Part B
I authorise Aviva, their agents and sub-contractors to discuss all aspects of the above numbered policy specific to the above named insured person
with the insured person.
Signature of the authorised official for policyholder/employer
Date
D D M M Y Y Y Y
Part C
I authorise Aviva, their agents and sub-contractors to discuss the following aspects of the above numbered policy specific to the above named
insured person with the insured person.
Please tick the appropriate box(es)
Definition of incapacity
Cease age
Deferred period
Exclusions applied to the policy
Overseas claims
Financial details (all)
Pension premium waiver (if applicable)
National Insurance contributions (if applicable)
Benefit calculation
Proportionate benefit
Linked periods of absence
Escalation basis
Other
Signature of the authorised official for policyholder/employer
Date
D D M M Y Y Y Y
Please now check you have completed the relevant section. Print off a copy if completed online (you may also wish to keep a copy
for your records), sign the form and return.
Aviva Health UK Limited. Registered in England Number 2464270. Registered Office 8 Surrey Street Norwich NR1 3NG.
Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the
Prudential Regulation Authority. Firm Reference Number 308139. www.aviva.co.uk/health
This insurance is underwritten by Aviva Life & Pensions UK Limited. Registered in England No 3253947.
2 Rougier Street, York, YO90 1UU. Authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority. Firm Reference Number 185896. www.aviva.co.uk
Aviva Health UK Limited, Head Office: Chilworth House Hampshire Corporate Park Templars Way Eastleigh Hampshire SO53 3RY.
CMSG002 07/2014 © Aviva plc
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Group Income Protection Claim Form Employer Questionnaire