Data collection form - Zurich Intermediary

Data collection form
Decreasing Mortgage Cover Plan
Level Protection Plan
Adaptable Life Plan
This is not an application form and is for Intermediary use only
Client(s) name(s):
1st life:
2nd life:
Decreasing Mortgage Cover Plan
Level Protection Plan
Adaptable Life Plan
When to use this form
This form is NOT an application form and is only to be used for the interim collection of data from your client to help you with the subsequent
completion of an online application on their behalf.
Intermediary guidance
Answering the questions – your duty to take reasonable care
Please fully complete all the relevant questions in this form.
• As the information you give me will be used to help me answer
Zurich’s questions on the application form and any subsequent
questions they ask, it is essential that you answer all the questions
honestly and accurately and to the best of your knowledge.
Before completing this form, please ensure your client receives a
copy of and reads Zurich’s data protection leaflet. ‘Your privacy is
important to us’ available from the Zurich Extranet or you can obtain
a copy at www.zurich.co.uk. Please also read the accompanying
important notes to your client and ensure that your client is fully
aware of their importance.
If your client does not want you to know the answer to one or more
of the medical questions they will need to apply in writing rather than
electronically. After receiving a copy of Zurich’s data protection
leaflet, they should submit a fully completed paper application form
direct to Zurich’s Chief Medical Officer at Zurich Assurance Ltd,
Tricentre One, New Bridge Square, Swindon SN1 1HN, marked
‘Confidential – Application Questions’.
The forms on pages 25 to 30 are for your use should you need
them during your client meeting; they do not form part of the
online submission for an underwriting decision. If used you will
need to complete and send them to Zurich Assurance Ltd, at the
above address.
How to contact us
Call us on 0500 546546 between Monday to Friday 8.30am to 6pm.
We may record or monitor calls to improve our service.
These are important notes that you need to read to
your client
The form that we are about to complete together is designed to
help me gather the necessary information from you so that I can
subsequently complete an online application to Zurich Assurance Ltd
(Zurich) on your behalf. As you will not be present when I complete
and submit the application(s), it is important that I take this
opportunity to bring certain important matters to your attention.
If there are any answers to the medical questions that you do not
wish me to know, I will not be able to apply online for you. Instead
you will need to complete a paper application form and send it direct
to Zurich. I can help you complete most of that form leaving you to
fill in the questions that you want to keep private from me.
Please note
• Your application is subject to acceptance by Zurich.
• Completing and submitting an application does not guarantee that
Zurich will accept your application and, if they do, on what terms.
• The collection of any payment by Zurich after receiving your
application does not necessarily mean that your application has
been accepted. Zurich will let you know whether, or not, they have
accepted your application.
• The standard terms and conditions for the plan applied for are
available on request from Zurich Assurance Ltd, Tricentre One,
New Bridge Square, Swindon SN1 1HN.
• Please don’t assume Zurich will contact your doctor, to ask for any
medical or other information.
• You need to let Zurich know in writing if there is any change to
your personal health (whether or not you seek or intend to seek
medical advice), family history, occupation, travel, hazardous
activities, alcohol consumption, smoking habits or use of
recreational drugs, that happens before the plan starts, if that
change makes any of your answers to the questions Zurich asked
wrong or incomplete. If your application is accepted you do not
have to tell Zurich about any changes that happen after your plan
has started unless Zurich ask you to if you apply for an increase or
extension in cover.
• You need to make sure that your answers are recorded completely
and accurately. Zurich’s decision to offer cover, and the terms of
that cover, will be based upon the recorded answers and won’t
take into account any verbal information that has not been
confirmed in writing.
• Zurich will send you a summary of the questions asked and the
answers you have given. You need to make sure the answers are
accurate and complete and, if they are not, you must immediately
let Zurich know in writing.
• If you don’t answer the questions correctly the plan may be
cancelled or its terms may be changed, or a claim may be rejected
or not fully paid. Cancelling a plan means that no cover or other
benefits will be provided.
• As your adviser I am your agent, not Zurich’s. I act for you,
not Zurich.
Genetic tests
• You must tell Zurich if you have had a genetic test for Huntington’s
disease if you are applying for more than £500,000 of life cover.
This limit includes any existing cover you have with Zurich.
• If you wish to tell Zurich about a negative genetic test result,
which shows that you have not inherited a genetic disorder,
Zurich will take this into account when assessing your application
provided that your clinical geneticist confirms to Zurich, in writing,
that the test result indicates you have a reduced risk of developing
the inherited disease.
• You must tell Zurich if you have a family history of, are experiencing
symptoms of, or are having treatment for, a medical condition
including any genetically inherited condition.
Access to medical reports
If Zurich needs a report from your doctor they will explain your rights
and obtain your written consent.
• Zurich policies are only suitable for customers who are UK residents.
2
Data protection – your information
Declaration
You must read the data protection leaflet ‘Your privacy is important
to us’ as this explains how your data will be used. If you do not
understand any of the information set out in the leaflet, please ask
for more information. Any application will contain a declaration that
you have read the leaflet.
• Any application will also contain your consent to:
– personal data (including medical and court proceeding details)
being used in the way described in the leaflet;
– Zurich using a reference agency for identity verification and
fraud checking purposes;
– Zurich obtaining medical information from any doctor you have
consulted about your physical or mental health, in order to
assess the application;
– Zurich, its agents, the Zurich Group, and any companies they
become associated with, using your information for setting up,
processing and administering your plan(s). Where we talk about
the Zurich Group in this form, we mean Zurich Financial
Services and its subsidiaries;
– your personal details (excluding medical details) being used,
passed to and shared by Zurich, its agents, the Zurich Group
and any companies they become associated with, so that they
can contact you (by mail, email, telephone or other appropriate
means) about carefully selected products, services or offers they
believe will be of interest to you.
Do you want to be contacted in this way?
(tick as appropriate)
Yes
No
• You authorise those asked by Zurich for such information to
provide it on production of a copy of consent.
• Your doctor or other medical practitioner may choose to fax
medical data to Zurich if Zurich needs this information to decide
whether to offer you cover and on what terms. They will be given
Zurich’s underwriting fax machine number, which is located within
Zurich’s underwriting department and is regularly attended by
underwriting staff. It is not used for general faxed communications.
• Zurich’s confidentiality policy means that your medical data is held
securely and access limited to appropriate individuals with a
business need to see it.
Any application will contain the following declaration:
• I/We have answered the questions in this application, and in any
additional forms completed in connection with the application,
honestly and accurately and the information I/we have provided in
response to the questions is, to the best of my/our knowledge,
complete and correct.
• I/We will tell Zurich about any change to my/our personal health,
family history of disease, driving convictions, occupation, travel,
hazardous activities, alcohol consumption, smoking habits or use
of recreational drugs, that happens before the plan starts, if that
change makes any of my/our answers to the questions Zurich
asked wrong or incomplete. I am/We are aware that if I/we
haven’t answered the questions correctly the plan may be
cancelled, or its terms may be changed, or a claim may be rejected
or not fully paid. Cancelling a plan means that no cover or other
benefits will be provided.
I am/We are aware that:
• Where applicable, Zurich can decline the Waiver of Payment
benefit and/or the Total Permanent Disability (own occupation) on
my life/either or both our lives (as appropriate). Zurich does not
need to tell me/us that either, or both, of these benefits has/have
been declined before issuing the plan(s). The plan schedule will say
if a benefit has been included.
• Where the plan provides Waiver of Payment benefit, the benefit
will not be paid in respect of any illness or disability which arises
from any condition that I/we had before the plan started.
• Zurich can also exclude, where applicable, the guaranteed
insurability option or special event benefit from the plan(s). Zurich
does not need to tell me/us that this option has been excluded
before issuing the plan(s). The plan schedule will say if this option
has not been included.
For plans being issued subject to the Relevant Life Policy
Trust only
Please note that if the plan continues after your employment with
the principal employer ends the terminal illness benefit will stop.
The plan’s terms and conditions will be changed to say this.
• Any relevant information obtained by Zurich during the assessment
of your application, in addition to that provided in the application,
may be used as part of that assessment and as part of the
administration of any claim. Where the application is made on a
joint life basis, and where it is reasonable and appropriate to do
so, information relating to either party may be considered in
relation to the other.
• If you do not wish me (your adviser) to know the answer to
any one or more of the questions on this data collection
form, you will need to fully complete a separate paper
application form in private and send it direct to Zurich’s
Chief Medical Officer, at Zurich Assurance Ltd, Tricentre
One, New Bridge Square, Swindon SN1 1HN, marked
‘Confidential – Application Questions’.
3
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Personal contact details
First life assured
Mr
Mrs
Miss
Other title
Is this life assured also the plan owner?
Yes
Surname
If No, complete the applicants details on the next page
Full forename(s)
Telephone no. (Evening)
Address
Telephone no. (Daytime)
No
Email address
Female
Male
Sex
Nationality
Previous name (if applicable)
Date of birth
D D
M M
Y Y Y Y
Second life assured
Mr
Mrs
Miss
Other title
Is this life assured also the plan owner?
Yes
Surname
If No, complete the applicants details on the next page
Full forename(s)
Telephone no. (Evening)
Address
Telephone no. (Daytime)
No
Email address
Male
Sex
Female
Nationality
Previous name (if applicable)
Date of birth
D D
M M
Y Y Y Y
4
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Life of another – applicant(s) details
Only complete if the plan owner(s) are different to the life/lives assured. If the plan is to be issued to the trustees of an existing trust, please
make sure they are aware that all correspondence and notices will be sent to the first named trustee only, except for cancellation notices which
will be sent to each applicant.
Full name
Full name
Address
Address
Nationality
Nationality
Full name
Full name
Address
Address
Nationality
Nationality
Corporate
If your client is applying for a plan that will be issued subject to the Relevant Life Policy Trust you need to make sure they are aware that if the
plan continues after the life to be assured’s employment ends, the terminal illness benefit will stop. The plan’s terms and conditions will be
changed to say this.
Company name
Location of business (full operating address)
Insurable interest
Please supply details of insurable interest
5
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Cover details
Decreasing Mortgage Cover Plan
D D
Start date
Term in years
M M
Y Y Y Y
Plan type
Single life
Joint life
Guaranteed rate
Life or earlier Critical Illness cover £
or
Life cover only
£
Payment amount
£
with
Monthly
Total Permanent Disability (TPD) own occupation
(Only available if you select life or earlier Critical Illness cover)
£
extra life cover of
Yearly
1st life
2nd life
Both lives
Not required
If Total Permanent Disability own occupation and/or Payment Protection Benefit is required please complete the occupation details on
page 19.
Payment Protection Benefit (PPB)
1st life
2nd life
Both lives
1st life
Payment Protection Benefit amount
Current annual earnings
2nd life
£
£
£
£
What percentage of earnings are paid as bonus
and/or commission?
Deferred period 3, 6 or 12 months
Not required
%
%
months
months
Waiver Of Payment
(do not complete for those lives selecting PPB)
1st life
2nd life
Both lives
Not required
6
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Cover details
Level Protection Plan
D D
Start date
Term in years
M M
Y Y Y Y
Plan type
Single life
Joint life
Guaranteed rate
Term options
Term
Convertible term – life cover only
Life or earlier Critical Illness cover £
or
Life cover only
£
Payment amount
£
with
1st life
£
extra life cover of
Monthly
Total Permanent Disability (TPD) own occupation
Renewable term
2nd life
Yearly
Both lives
Not required
Only available if you select life or earlier Critical Illness cover
If Total Permanent Disability own occupation and/or Payment Protection Benefit is required please complete the occupation details on
page 19.
Indexation
AWE%
RPI%
Payment protection benefit (PPB)
1st life
2nd life
5%
10%
Not required
Both lives
Not required
Not available if you select either of the renewable or convertible term options.
1st life
Payment protection benefit amount
Current annual earnings
2nd life
£
£
£
£
What percentage of earnings are paid as bonus
and/or commission?
Deferred period 3, 6 or 12 months
%
%
months
months
Waiver Of Payment
1st life
(do not complete for those lives selecting PPB)
2nd life
Both lives
Not required
Cover details
Adaptable Life Plan
Start date
D D
Plan type
M M
Single life
Y Y Y Y
Joint life First Death
Joint life Second Death
Guaranteed rate
Life cover
£
Payment amount
£
Indexation
AWE%
Not required
Waiver Of Payment
1st life
2nd life
Both lives
Monthly
Yearly
Not required
7
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Health and medical details
1st life
2nd life
Height and weight
What is your height? ftin
or cms
What is your height? ftin
or cms
What is your weight? stlbs
or kgs
What is your weight? stlbs
or kgs
Tobacco and Smoking
Non-smoker rates apply where the customer confirms they have not used any tobacco products, including nicotine substitutes in the last
12 months.
1st life
Have you smoked or used any form of tobacco
or nicotine product in the past 12 months?
Yes
2nd life
No
– please answer the
questions in the grey
section below
Yes
I have never smoked
I have never smoked
I used to smoke but I gave up
If “Yes”, please state amount smoked on average
each day
Do you use e-cigarettes containing nicotine or any other
tobacco or nicotine product?
No
– please answer the
questions in the grey
section below
I used to smoke but I gave up
between
1&3
years ago
between
1&3
years ago
between
3&5
years ago
between
3&5
years ago
between
5 & 10
years ago
between
5 & 10
years ago
over 10 years ago
over 10 years ago
Cigarettes
Cigarettes
Cigars
Cigars
grams of tobacco
Yes
No
grams of tobacco
Yes
No
Alcohol Consumption
Do you drink alcohol?
If “Yes” how often do you have a drink containing
alcohol?
How many drinks containing alcohol do you have on a
typical day when you are drinking?
Yes
No – go to next question
Yes
No – go to next question
once a month or less
once a month or less
2 to 4 times a month
2 to 4 times a month
2 or 3 times a week
2 or 3 times a week
4 or more times a week
4 or more times a week
1 or 2 drinks
1 or 2 drinks
3 or 4 drinks
3 or 4 drinks
5 or 6 drinks
5 or 6 drinks
7, 8 or 9 drinks
7, 8 or 9 drinks
10 or more drinks
10 or more drinks
8
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Health and Medical details (continued)
1st life
2nd life
Alcohol Consumption
Have you ever been advised or treated for alcohol
consumption or abuse, or attended an alcohol
support group, or been told you have any liver
damage?
If “Yes” how long ago was this?
Yes
No – go to next question
Yes
No – go to next question
up to 6 months ago
up to 6 months ago
6 months to 12 months ago
6 months to 12 months ago
over 12 months ago
over 12 months ago
What was the reason for this?
Drug use
In the last 10 years, have you used recreational
drugs such as cannabis, ecstasy, cocaine, heroin,
amphetamines, or anabolic steroids?
Yes
No – go to next question
Yes
No – go to next question
cannabis
cannabis
ecstasy
ecstasy
cocaine
cocaine
heroin
heroin
amphetamines
amphetamines
anabolic steroids
anabolic steroids
other drugs
other drugs
If other drugs please specify
If other drugs please specify
If “Yes” to any drug please confirm for each drug
Drug 1
Which drug did you use?
Do you or did you inject this type of drug?
Yes
No
Yes
No
Yes
No
Yes
No
When was the last time you used this drug?
Drug 2
Which drug did you use?
Do you or did you inject this type of drug?
When was the last time you used this drug?
If you have used more drugs please use a continuation sheet for this information.
9
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Medical history – Have you ever had?
1st life
Diabetes or sugar in the urine?
If “Yes” to type 1 or 2 diabetes please answer
the Diabetes additional questions on page 22.
Raised blood pressure or raised cholesterol?
If “Yes” please answer the raised blood pressure
or raised cholesterol additional questions on
page 22.
Any heart disease or disorder, such as heart
attack, angina, chest pain, cardiomyopathy,
heart murmur, narrow or leaky heart valves,
or heart surgery?
Yes
No – go to next question
type 2 – treated with diet or tablets
type 2 – treated with diet or tablets
type
2 – treated with insulin
gestational diabetes
type
2 – treated with insulin
gestational diabetes
sugar in the urine
sugar in the urine
Yes
No – go to next question
No – go to next question
raised blood pressure
raised cholesterol
raised cholesterol
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Specify condition(s)
Cancer, leukaemia, Hodgkin’s disease,
melanoma, lymphoma, brain or spinal tumours
or growths?
Yes
raised blood pressure
Specify condition(s)
Any brain disease or disorder such as stroke,
brain haemorrhage, transient ischaemic attack
(TIA) or mini stroke, aneurysm, meningitis, any
brain damage, or been in a coma?
No – go to next question
type 1 diabetes
Specify condition(s)
Any heart rhythm abnormalities such as
atrial fibrillation, fast or slow heart rate
or palpitations?
Yes
type 1 diabetes
Specify condition(s)
A disorder or abnormality of the blood vessels
or arteries such as narrowing, blockages,
blood clots or deep vein thrombosis (DVT)?
2nd life
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
10
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Medical history – Have you ever had?
Schizophrenia, bi-polar disorder, manic
depression, attempted suicide, episode of self
harm, an eating disorder, or any other mental
illness that has required a stay in hospital or
referral to a psychiatrist?
1st life
Yes
No – go to next question
2nd life
Yes
No – go to next question
bi-polar disorder
bi-polar disorder
clinical depression
clinical depression
eating
disorder – anorexia
or bulimia
eating
disorder – anorexia
or bulimia
episode of self harm
episode of self harm
manic depression
manic depression
paranoia
paranoia
personality disorder
personality disorder
post-traumatic stress disorder
post-traumatic stress disorder
psychosis
psychosis
schizophrenia
schizophrenia
suicide attempt /overdose
suicide attempt /overdose
other
mental illness requiring
hospitalisation or psychiatric
referral
other
mental illness requiring
hospitalisation or psychiatric
referral
If “Yes” to “other mental illness” please provide
the name of the condition.
Any disorder of the nervous system such as
multiple sclerosis, Devic’s disease, optic neuritis,
Parkinson’s disease, paralysis, cerebral palsy,
motor neurone disease, dementia, memory loss
or impairment?
Yes
Any disease or disorder of the liver or pancreas
such as any form of hepatitis, abnormal liver
function test, fatty liver, cirrhosis or
pancreatitis?
Yes
No – go to next question
Specify condition(s)
No – go to next question
Specify condition(s)
A positive test for HIV or are you awaiting
the results of an HIV test?
If “HIV positive” please give details of when you
were diagnosed and what treatment you received
or are receiving
Yes
No – go to next question
HIV
positive
awaiting
HIV test results
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
HIV
positive
awaiting
HIV test results
If “awaiting HIV test” when do you expect the
test results to be available?
11
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Recent health – In the last 5 years, have you had:
Anxiety, stress, depression, chronic fatigue,
obsessive compulsive disorder, or other
mental illness?
If “Yes” please answer mental illness additional
questions on page 23.
1st life
Yes
No – go to next question
2nd life
Yes
No – go to next question
anxiety
anxiety
stress
stress
depression
depression
post natal depression
post natal depression
chronic fatigue
chronic fatigue
– obsessive
OCD
compulsive disorder
– obsessive
OCD
compulsive disorder
mental illness
other
mental illness
other
If “Yes” to “other mental illness” please provide
the name of the condition.
Any respiratory or lung disease or disorder such
as asthma, bronchitis, COPD or sarcoidosis?
If “Yes” to asthma, please complete the
additional asthma questions on page 24.
Yes
No – go to next question
Yes
No – go to next question
asthma
asthma
bronchitis
bronchitis
bronchiectasis
bronchiectasis
COPD
– chronic obstructive
pulomonary disease
COPD
– chronic obstructive
pulomonary disease
emphysema
emphysema
hayfever
hayfever
pleurisy
pleurisy
pneumonia
pneumothorax (collapsed lung)
pneumonia
pneumothorax (collapsed lung)
pulmonary embolism
pulmonary embolism
sarcoidosis
sarcoidosis
sleep
apnoea
other
respiratory disease/disorder
sleep
apnoea
other
respiratory disease/disorder
If “Yes” to “other respiratory disease/disorder”,
please provide the name of the condition.
Any kidney disease or disorder such as any form
of nephritis, cysts or recurrent kidney stones?
Yes
No – go to next question
Specify condition(s)
Any disease or disorder of the bladder or urinary
tract such as recurrent infections or protein or
blood in urine?
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
12
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Recent health – In the last 5 years, have you had:
Epilepsy or seizure, a fit, fainting blackout
or loss of consciousness?
1st life
Yes
No – go to next question
2nd life
Yes
No – go to next question
epilepsy
epilepsy
seizure
seizure
fit
fit
fainting
fainting
blackout
blackout
loss
of consciousness
syncope
loss
of consciousness
syncope
neurological disease/
other
disorder
neurological disease/
other
disorder
If “Yes” to “other neurological disease/disorder”,
please provide the name of the condition.
Any thyroid disorder?
Yes
No – go to next question
Yes
No – go to next question
overactive thyroid
overactive thyroid
underactive thyroid
underactive thyroid
thyroiditis
thyroiditis
goitre
goitre
other
thyroid problem
other
thyroid problem
If “Yes” to “other thyroid problem” please provide
the name of the condition.
Any disease or disorder of the stomach, bowel
or digestive system such as ulcers, ulcerative
colitis, or Crohn’s disease?
Yes
No – go to next question
Specify condition(s)
Any tremor, numbness, loss of feeling or
tingling in the limbs or face, loss of balance
or co-ordination or loss of muscle power?
Yes
No – go to next question
Specify condition(s)
Any weight loss treatment such as medication,
gastric banding or bypass?
Yes
No – go to next question
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
weight loss medication
weight loss medication
gastric banding
gastric banding
gastric bypass
gastric bypass
other weight loss treatment
other weight loss treatment
If “Yes” to “other weight loss treatment”,
please provide the name of the treatment.
13
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Recent health – In the last 5 years, have you had:
Any disease or disorder of the skin such as
psoriasis or a mole or freckle that has bled or
changed in appearance?
Yes
1st life
No – go to next question
Specify condition(s)
Anaemia or other blood disorders such as
haemochromatosis or haemophilia?
Yes
No – go to next question
Specify condition(s)
Any disease or disorder of the back, bones or
joints, such as arthritis, whiplash, sciatica,
slipped disc or gout?
Yes
No – go to next question
Specify condition(s)
2nd life
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
For males only
Any disease or disorder of the prostate or
testicle, such as raised prostate specific antigen
(PSA) or undescended testicle?
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
For females only
Any biopsy or ultrasound of the breast, cervix,
ovary or uterus, or an abnormal mammogram
or an abnormal cervical smear? (You don’t need
to tell us about any tests in connection with
routine pregnancy.)
Yes
No – go to next question
Yes
No – go to next question
breast biopsy
breast biopsy
breast ultrasound
breast ultrasound
cervix biopsy
cervix biopsy
cervix ultrasound
cervix ultrasound
ovary biopsy
ovary biopsy
ovary
ultrasound
uterus
biopsy
ovary
ultrasound
uterus
biopsy
uterus
ultrasound
abnormal
cervical smear
uterus
ultrasound
abnormal
cervical smear
abnormal mammogram
abnormal mammogram
14
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Recent health – In the last 5 years, have you had:
1st life
2nd life
Please complete these two additional questions if you are applying for Critical Illness cover, Total Permanent Disability
(Own Occupation) benefit, Payment Protection benefit or Waiver of Payment benefit.
Any sight impairment or loss, blurred or double
vision or other problems in one or both eyes?
(You don’t need to tell us about sight problems
corrected by glasses or contact lenses.)
Yes
No – go to next question
Specify condition(s)
Any hearing impairment or loss, dizziness,
ringing or other disorder in one or both ears
such as tinnitus, labyrinthitis or Meniere’s
disease?
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Yes
No – go to next question
Specify condition(s)
Please complete the questions below for ALL benefits
Other than for the conditions you have already told us about earlier in this application:
Are you aware of any symptoms that you
intend to seek medical advice or treatment
for, or are you waiting for any test results,
appointments or investigations with your
doctor or other medical professional?
Yes
No – go to next question
Yes
No – go to next question
intend
to seek medical advice
or treatment
intend
to seek medical advice
or treatment
waiting
for a test result,
appointment or investigation
waiting
for a test result,
appointment or investigation
Yes
Yes
If you intend to seek medical advice or treatment,
please give full details why.
When do you intend to do this?
If you have been referred to a specialist, why was
this?
When do you expect to be seen?
If you have undergone investigations or tests,
what have you had?
When were these done?
Do you know the results yet?
No
No
If “Yes”, what were the results?
If “No”, when do you expect to know the results?
Are you currently taking drugs, medicines or
tablets or receiving any other treatment?
Yes
No – go to next question
Yes
No – go to next question
(You don’t need to tell us about oral
contraceptive treatment, Hormone Replacement
Therapy (HRT), iron supplements during pregnancy,
hay fever treatments or cold/flu remedies.)
Do these treatments relate only to medical
conditions you have already told us about?
Yes
No
Yes
No
If “No”, please give full details of the type of drugs,
medicines, tablets or other treatment and the
condition or symptoms being treated.
15
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Recent health – In the last 5 years, have you had:
In the last 3 months have you had any
symptoms of ill health such as unexplained
bleeding, weight loss, change of bowel habit,
unexplained lump or growth, breathing
problems or shortness of breath, or a cough
that’s lasted for 4 weeks or more?
Yes
1st life
No – go to next question
2nd life
Yes
No – go to next question
unexplained bleeding
unexplained bleeding
unexplained weight loss
unexplained weight loss
change of bowel habit
change of bowel habit
unexplained lump or growth
unexplained lump or growth
breathing
problems or shortness
of breath
breathing
problems or shortness
of breath
a cough that’s lasted 4 weeks
or more
a cough that’s lasted 4 weeks
or more
other symptoms of ill health
other symptoms of ill health
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If “Yes” to “other symptoms of ill health” then
please provide details of the symptoms.
When did this start?
Have you seen a doctor for this?
If “Yes”, are you awaiting any further tests,
investigations or referral to a specialist?
If “Yes”, when is the next appointment due?
If “No” (to have you seen a doctor for this),
are you intending to see a doctor?
If “Yes”, when do you expect to be seen?
Have you had more than 10 days’ sick leave in
the last year?
Yes
No – go to next question
Yes
No – go to next question
If “Yes”, in total, how many days was this?
Please provide reasons for the absence
Family History
Have any of your natural parents, brothers or sisters been diagnosed with any of the following before their 65th birthday:
Breast, bowel/colon, ovarian* or other cancer?
Yes
No – go to next question
Yes
No – go to next question
Condition 1
Condition 1
Number of relatives
Number of relatives
Age at onset of disease:
Age at onset of disease:
Youngest
Youngest
2nd youngest
2nd youngest
16
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Family history (continued)
1st life
2nd life
Condition 2
Condition 2
Number of relatives
Number of relatives
Age at onset of disease:
Age at onset of disease:
Youngest
Youngest
2nd youngest
2nd youngest
*For female applicants with a family history of ovarian cancer please answer the following questions:
As a result of your family history of ovarian
cancer, have you needed any tests, investigations
or treatment, including the removal of both
ovaries (a bilateral oophorectomy)?
Please note, if you wish to tell us about a
negative genetic test result, which shows that
you have not inherited a genetic disorder, we will
take this into account.
Diabetes, heart attack, angina, stroke or
heart disease?
Yes
No – go to next question
Yes
No – go to next question
If “Yes”, please give the following
details:
If “Yes”, please give the following
details:
Date(s)/Type/Results/Outcome
Date(s)/Type/Results/Outcome
Details of any planned review or
follow up
Details of any planned review or
follow up
Yes
No – go to next question
Yes
No – go to next question
Condition 1
Condition 1
Number of relatives
Number of relatives
Age at onset of disease:
Age at onset of disease:
Youngest
Youngest
2nd youngest
2nd youngest
Condition 2
Condition 2
Number of relatives
Number of relatives
Age at onset of disease:
Age at onset of disease:
Youngest
Youngest
2nd youngest
2nd youngest
17
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Family history (continued)
Multiple sclerosis, Alzheimer’s disease,
Parkinson’s disease, cardiomyopathy*, motor
neurone disease, polycystic kidney disease**,
Huntington’s disease, muscular dystrophy,
retinitis pigmentosa, polyposis coli or any
other hereditary disorder?
1st life
Yes
No – go to next question
2nd life
Yes
No – go to next question
Condition 1
Condition 1
Number of relatives
Number of relatives
Age at onset of disease:
Age at onset of disease:
Youngest
Youngest
2nd youngest
2nd youngest
Condition 2
Condition 2
Number of relatives
Number of relatives
Age at onset of disease:
Age at onset of disease:
Youngest
Youngest
2nd youngest
2nd youngest
*If you have a family history of cardiomyopathy, please answer the following questions:
As a result of your family history of
cardiomyopathy, have you had any investigations?
Please note, if you wish to tell us about a negative
genetic test result, which shows that you have
not inherited a genetic disorder, we will take this
into account.
Yes
No – go to next question
Yes
No – go to next question
If “Yes”, please give the
following details:
If “Yes”, please give the
following details:
Date(s)/Type/Results/Outcome
Date(s)/Type/Results/Outcome
Details of any planned review or
follow up
Details of any planned review or
follow up
**If you have a family history of polycystic kidney disease, please answer the following questions:
As a result of your family history of polycystic
kidney disease, have you had a CT scan or
ultrasound scan?
Please note, if you wish to tell us about a negative
genetic test result, which shows that you have
not inherited a genetic disorder, we will take this
into account.
Yes
No – go to next question
Yes
No – go to next question
If “Yes”, how old were you when these
investigations were last carried out?
If “Yes”, how old were you when these
investigations were last carried out?
Were the results of the investigations
normal or negative?
Were the results of the investigations
normal or negative?
Yes
Don’t know
No
Yes
No
Don’t know
18
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Occupation
1st life
2nd life
What is your occupation?
Does your occupation involve: working
externally at heights over 50ft (15m)*, offshore
in oil, gas or fishing industries*, underground*,
handling explosives*, flying, diving*, or are
you in the armed forces, including reserve or
territorial forces?
Yes
No – go to next question
Yes
No – go to next question
orking externally at heights
w
over 50 feet /15 metres
orking externally at heights
w
over 50 feet /15 metres
orking offshore in the oil or
w
gas industry
orking offshore in the oil or
w
gas industry
orking offshore in the
w
fishing industry
orking offshore in the
w
fishing industry
working underground
working underground
handling explosives
handling explosives
diving
diving
ying (please complete an
fl
aviation questionnaire)
ying (please complete an
fl
aviation questionnaire)
ember of the armed forces
m
or armed forces reserves
(please complete an armed
forces questionnaire)
ember of the armed forces
m
or armed forces reserves
(please complete an armed
forces questionnaire)
If you have answered “Yes” to the items marked with a * we will require additional information so please also complete an
Occupation Questionnaire. If you do this before you complete the online application you will have an opportunity to provide
the information electronically.
Please answer the four questions below if you are applying for Total Permanent Disability own occupation or Payment Protection
Benefit.
Do you work less than 16 hours per week?
Yes
No – go to next question
Yes
No – go to next question
Do you drive more than 20,000 miles a year as
part of your work, excluding driving to and from
your usual place of work?
Yes
No – go to next question
Yes
No – go to next question
Do you work with machinery or tools or does
your work involve bending, lifting or carrying
heavy items?
Yes
No – go to next question
Yes
No – go to next question
If “Yes”, how much of your time do you spend
using machinery or tools, bending, lifting or
carrying heavy items?
Are any of your earnings based on commission?
If “Yes”, how much of your earnings are based
on commission?
1–10%
1–10%
11–20%
11–20%
21–50%
21–50%
over
50%
over
50%
Yes
No – go to next question
Yes
No – go to next question
1–10%
1–10%
11–20%
11–20%
21–30%
21–30%
31–50%
31–50%
51%
or more
51%
or more
19
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Other information
Will the amount of cover you are now applying
for, added to the amount you already hold with
any insurance company, exceed £1million life
cover or £500,000 Critical Illness cover?
(You don’t need to include any other cover
that you don’t intend to proceed with.)
1st life
2nd life
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Yes
No – go to next question
Travel
In the last 5 years, have you spent more than
30 consecutive days in Africa, Thailand, The
Caribbean, Russia, Ukraine, Afghanistan, Iraq,
Syria or area of civil unrest?
If “Yes”, where did you travel to?
When did you travel there?
How long did you travel there for?
What was the reason for the travel?
In the next 2 years, do you expect to travel,
live or work outside the United Kingdom,
European Union, North America, Australia or
New Zealand. (You don’t need to tell us about
a total of 30 days holiday each year or the
reason for your travel.)
If “Yes” please provide the country and how
long you intend to spend in this country each year
(in weeks)
Activities
Do you take part, or intend to take part in
diving, caving or potholing, climbing or
mountaineering outside the UK, flying or other
aviation based activity (other than as aircrew
or as a fare paying passenger), motor sport,
or other hazardous pursuit? (You don’t need
to tell us about gift experiences, track days,
charity parachute jumps or try dives.)
diving
diving
caving or potholing
caving or potholing
climbing or mountaineering
climbing or mountaineering
flying
or other aviation
based activity
flying
or other aviation
based activity
motor
sport
hazardous pursuit
other
motor
sport
hazardous pursuit
other
If “Yes” to “other hazardous pursuits” please give
details of the pursuit.
20
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Activities (continued)
1st life
In the last 5 years, have you been banned
from driving?
Yes
2nd life
No – go to next question
Yes
No – go to next question
If “Yes”, when were you banned from driving?
Please tell us why you were banned from driving
drink-driving
drink-driving
drug-driving
drug-driving
speeding
speeding
accumulation
of penalty
points (endorsements)
accumulation
of penalty
points (endorsements)
other
reasons
other
reasons
Yes
Yes
If “Yes” to “other reasons” please give the reason
If the reason was other than “speeding” or
“accumulation of penalty points” please also
answer the following questions.
Has the DVLA given you your licence back?
No
No
If “No”, when do you expect to get your
licence back?
Doctors details
Asking for this doesn’t mean we’ll automatically request a medical report.
We need the name and address of the doctor who
holds your medical records. If you don’t currently have
a doctor please provide details of a previous doctor.
If you have never been registered with a doctor,
please state ‘no doctor’.
Dr
Initials
Dr
Initials
Surname
Surname
Address
Address
Telephone
Telephone
21
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
If you have answered Yes to any of the additional questions, please complete the below, otherwise please go to the
Instruction to your bank or building society to pay by direct debit
Additional questions
1st life
2nd life
Diabetes additional questions
How long ago was your diabetes diagnosed?
Since you were told you had diabetes, have you
been admitted to hospital for one night or more
due to your diabetes?
Have you ever had, been advised to have or are or
are waiting to have laser treatment to your eyes
due to diabetes?
Have you ever been told by your GP or any medical
professional that you have protein in your urine due
to diabetes?
Do you have, or ever had, tingling, numbness or
loss of sensation in your fingers, toes or feet due
to diabetes?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
What was your latest HbA1c and when was this?
Date
Raised blood pressure additional questions
How long ago was your blood pressure first found
to be raised?
Are you currently receiving any treatment or
medication for your blood pressure?
How long ago was your blood pressure last
checked by a doctor or nurse?
Have you been told by a doctor that your blood
pressure is normal?
Have you had or are you waiting for any hospital
tests or investigations related to your raised blood
pressure, such as heart investigations, kidney tests
or eye screening?
Don’t know
Don’t know
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Raised cholesterol additional questions
Have you been told that your raised cholesterol is
linked to a family history of raised cholesterol?
How long ago was your cholesterol first found to
be raised?
Are you currently receiving any treatment or
medication for your cholesterol?
How long ago was your cholesterol last checked by
a doctor or nurse?
Have you been told by a doctor that your
cholesterol is normal?
Have you had or are you waiting for any hospital
tests or investigations related to your raised
cholesterol, such as heart investigations or
kidney tests?
Don’t know
Yes
Don’t know
No
Yes
No
22
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Additional questions (continued)
1st life
2nd life
Mental illness additional questions
Are you currently taking any treatment or
receiving counselling, or have you done so
in the last 12 months?
Yes
How many days, in total, have you had off work
or from your normal activities due to this
condition in the last 12 months?
No
time off work required
or normal duties
No
time off work required
or normal duties
1 to 5 days
1 to 5 days
6 to 10 days
6 to 10 days
11 to 20 days
11 to 20 days
more than 20 days
more than 20 days
no longer able to work
no longer able to work
ongoing symptoms
ongoing symptoms
symptoms in the last 6 months
symptoms in the last 6 months
no symptoms in the last 6 months
no symptoms in the last 6 months
Yes
Yes
Do you have ongoing symptoms or have you had
any symptoms in the last 6 months?
Have you ever been treated as a hospital in-patient
or by a psychiatrist?
Have you ever planned or attempted suicide
or self harmed?
No
No
Yes
No
No
treated as a hospital in-patient
treated as a hospital in-patient
treated by a psychiatrist but not
as an in-patient
treated by a psychiatrist but not
as an in-patient
Yes
Yes
No
No
planned suicide but not attempted
planned suicide but not attempted
attempted suicide
attempted suicide
self harmed
self harmed
If yes, when was the last time
Please give as much information as you can
about your condition including the treatment
given, cause of the condition, date of last
symptoms and frequency of episodes.
If ‘Yes’ to post natal depression please answer
the following questions in addition to the above
Are you currently pregnant
Yes
No
Yes
No
If ‘Yes’ when is your baby due?
23
Before you complete this form, you need to make sure your client is fully aware of the information set out in the section headed
‘Answering the questions – your duty to take reasonable care’ on page 2. Please make sure you record your client’s answers accurately.
Additional questions (continued)
1st life
2nd life
Asthma additional questions
Have you been admitted to hospital for your
asthma within the last 5 years?
Yes
If ‘yes’ when were you admitted?
Within the last 6 months
Within the last 6 months
6 to 12 months ago
6 to 12 months ago
1 to 2 years ago
1 to 2 years ago
2 to 3 years ago
2 to 3 years ago
3 to 5 years ago
3 to 5 years ago
none in the last year
none in the last year
a few days a year
a few days a year
1 or 2 days a week
1 or 2 days a week
3 to 6 days a week
3 to 6 days a week
every day in the daytime only
every day in the daytime only
every
day, in the daytime and
at night
every
day, in the daytime and
at night
less than once a week
less than once a week
1 to 2 times a week
1 to 2 times a week
more than 2 times a week
more than 2 times a week
No
Yes
No
If you were admitted within the last year please
confirm which month
How often do you have symptoms, such as
wheezing, breathlessness, a cough or a
tight chest?
How often has your asthma affected your daily
activities in the last 2 years?
How many days have you lost from work or been
unable to carry out your normal daily activities in
the last 2 years?
24
Instruction to your bank or building society
to pay by direct debit
Service user number
Please fill in the whole form and send it to:
Zurich Assurance Ltd
UK Life Centre
Swindon
SN1 1HN
9
9
6
4
4
4
Instruction to your bank or building society
Please pay Zurich Assurance Ltd 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 Zurich Assurance Ltd and, if so, details will be passed
electronically to my bank/building society.
Name(s) of account holder(s)
Bank/building society account number Branch sort code
–
Signature(s)
–
Name and full postal address of your bank or building society
To: The Manager
Bank/building society
Address
Date
D D
M M
Y Y Y Y
Banks and building societies may not accept direct debit instructions for some types of account.
This is not part of the instruction to your bank or building society and
must be detached by Zurich Assurance Ltd before submission to the
paying bank.
Bank account holder declaration
Please complete if the person paying is not the life assured on this
plan. I understand Zurich may use a reference agency for
identification verification and fraud checking purposes.
Bank/building society account holder
The full name and address of the bank/building society account
holder should be completed if the person, organisation or company
making the payments is not a life assured on this plan.
Mr
Mrs
Miss
"
Other title
Surname
Full forenames
Signature(s)
Date of birth
D D
M M
Y Y Y Y
Nationality
Address
If a company makes the payments on this plan, please confirm the
registration number:
D D
M M
Y Y Y Y
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, Zurich Assurance Ltd will notify you 10 working days in
advance of your account being debited or as otherwise agreed. If you request Zurich Assurance Ltd 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 Zurich Assurance Ltd 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 Zurich Assurance Ltd 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.
"
Date
Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors and
attorneys acting under Power of Attorney and third parties where you have been required to undertake identification).
Confirmation of verification of identity certificate
(to be completed by an FCA Regulated or EU Regulated Introducer)
Name of applicant*/trustee*/third party*/Attorney* (delete as applicable)
Mr/Mrs/Miss
Other title
Surname
Full forename(s)
Address
Telephone number
Date of birth
D D
M M
Y Y Y Y
Nationality
Plan number
Previous address if moved in last three months
I/We certify that:
a) the information above was obtained by me/us in relation to the customer;
b) the evidence I/we have obtained to verify the identity of the customer: (tick one only)
meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG; or
exceeds the standard evidence (written details of the further verification evidence taken are attached to
this confirmation).
This certificate cannot be used to verify the identity of any customer that falls into one of the following categories:
• Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for
such verification;
• Those whose identity has not been verified by virtue of the application of a permitted exemption under the Money Laundering Regulations;
or
• Those whose identity has been verified using the ‘Source of funds’ as evidence.
If you have not verified the identity of the applicant, please give reasons below:
Adviser name
Address
Telephone number
Adviser code
Financial services register number
Name of person completing this certificate
Job title
Signature
Date
D D
M M
Y Y Y Y
Note this certificate must be signed by an officer of the introducer firm who is authorised to confirm the accuracy and
effectiveness of the firm’s customer identification verification records to which this certificate relates.
We cannot accept photocopies of completed certificates.
26
Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors and
attorneys acting under Power of Attorney and third parties where you have been required to undertake identification).
Confirmation of verification of identity certificate
(to be completed by an FCA Regulated or EU Regulated Introducer)
Name of applicant*/trustee*/third party*/Attorney* (delete as applicable)
Mr/Mrs/Miss
Other title
Surname
Full forename(s)
Address
Telephone number
Date of birth
D D
M M
Y Y Y Y
Nationality
Plan number
Previous address if moved in last three months
I/We certify that:
a) the information above was obtained by me/us in relation to the customer;
b) the evidence I/we have obtained to verify the identity of the customer: (tick one only)
meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG; or
exceeds the standard evidence (written details of the further verification evidence taken are attached to
this confirmation).
This certificate cannot be used to verify the identity of any customer that falls into one of the following categories:
• Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for
such verification;
• Those whose identity has not been verified by virtue of the application of a permitted exemption under the Money Laundering Regulations;
or
• Those whose identity has been verified using the ‘Source of funds’ as evidence.
If you have not verified the identity of the applicant, please give reasons below:
Adviser name
Address
Telephone number
Adviser code
Financial services register number
Name of person completing this certificate
Job title
Signature
Date
D D
M M
Y Y Y Y
Note this certificate must be signed by an officer of the introducer firm who is authorised to confirm the accuracy and
effectiveness of the firm’s customer identification verification records to which this certificate relates.
We cannot accept photocopies of completed certificates.
27
Please complete the certificate and complete separate certificates for all parties to the contract (e.g. joint applicants, trustees, settlors and
attorneys acting under Power of Attorney and third parties where you have been required to undertake identification).
Confirmation of verification of identity certificate
Corporate and other non-personal entity
Introduction by a FCA regulated firm
1. Details of customer
Full name of customer
Type of entity (corporate, trust, club, etc.)
Registered number, if any (or appropriate)
Relevant company registry or regulated market listing authority
Location of business (Address)
Names of directors or equivalent
Registered office (in country of incorporation)
Names of principal beneficial owners (Over 25%)
Relevant company registry includes Companies House, other registers, such as those maintained by charity commissions (or equivalent) or
chambers of commerce.
2. Confirmation
I/We certify that:
a) the information in section 1 above was obtained by me/us in relation to the customer;
b) the evidence I/we have obtained to verify the identity of the customer: (tick one only)
meets the standard evidence set out within the guidance for the UK Financial Sector issued by JMLSG; or
exceeds the standard evidence (written details of the further verification evidence taken are attached to
this confirmation).
This certificate cannot be used to verify the identity of any customer that falls into one of the following categories:
• Those who are exempt from verification as being an existing client of the introducing firm prior to the introduction of the requirement for
such verification;
• Those whose identity has not been verified by virtue of the application of a permitted exemption under the Money Laundering Regulations;
or
• Those whose identity has been verified using the ‘Source of funds’ as evidence.
If you have not verified the identity of the applicant, please give reasons below:
Signature
Name
Position
Date
D D
M M
Y Y Y Y
3. Details of introducing firm (or sole trader)
Full name of regulated firm (or sole trader)
Financial services Register number
Note this certificate must be signed by an officer of the introducer firm who is authorised to confirm the accuracy and
effectiveness of the firm’s customer identification verification records to which this certificate relates.
We cannot accept photocopies of completed certificates.
28
Access to Medical Reports
What are my access to medical reports rights?
This leaflet tells you why we ask you about your medical
history, why we might ask your doctor for medical reports and
what we do with the information given to us. It also explains
your rights under the Access to Medical Reports Act 1988 or
the Access to Personal Files and Medical Reports (Northern
Ireland) Order 1991.
We may need to apply to your doctor for a medical report and, if we
do, we’ll need your permission under the Access to Medical Reports
Act 1988 or the Access to Personal Files and Medical Reports
(Northern Ireland) Order 1991. Your legal rights are:
What information will be in the doctor’s report?
• You can ask to see the report before your doctor returns it to us.
If you do, we’ll ask your doctor to retain it for 21 days so that you
can arrange to see the report. This may cause a delay in processing
your application.
We use the details about your health, such as the information you
give us on your application form and the reports from your doctor,
to decide whether to offer you insurance and on what terms.
In this way, we ensure the cost of insurance for everyone is fair.
Our underwriters must work out what the risk of a person dying, or
suffering a serious illness, might be when calculating how much to
charge for insurance. We use statistics provided by various health
organisations that give us information about ‘the average person’.
We also look at an individual’s history of medical conditions and
lifestyle factors that could affect the likelihood of a person dying
prematurely or suffering a serious illness in the future. The underwriter
will be particularly interested in whether or not it’s possible for a
person to suffer from a number of critical illnesses that may be
covered by the plan applied for. Depending on the type of plan you’ve
applied for, the underwriter will also look at the possibility of the
applicant not being able to work because of ill health.
What information will be in the general practitioner’s
report?
The medical report your doctor fills in asks about:
Your current health:
• Care, medication or treatment you are receiving.
• Results of referrals or tests you are awaiting.
• 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, cardiovascular disease, diabetes, or degenerative
diseases;
– musculoskeletal disease or injury, for example, arthritis,
rheumatism, back problem or any other disorder of the
joints or muscles;
– anxiety state, depression, neurosis, psychosis, stress or fatigue;
– suicidal tendencies or attempts;
– conditions related to drug or alcohol misuse and/or tobacco
consumption.
• Details of biopsies, blood tests, electrocardiograms, height, weight
if measured in the last two years, urinalyses, x-rays or
other investigations.
• You don’t have to give your consent, but if you don’t we may not
be able to proceed. This doesn’t stop you applying elsewhere.
• You can ask your doctor for a copy of the report at any time
during the six months after it has been sent to us.
• You can ask your doctor to amend the report if you consider any
aspect of the report to be incorrect or misleading. If your doctor
refuses to make the amendments, you may add your comments to
the report.
• Your doctor can refuse you access to the report if he feels this
would cause physical or mental harm to you or others.
• Your medical report will contain details of relevant illness, trauma,
referrals for specialist advice or treatment, hospital admissions,
operations, consultations, investigations and test results that you
have undergone at any surgery, hospital or clinic. It will also
include details of any family history of disease that you have told
your doctor about.
• Your consent will enable us to obtain information about your
physical or mental health from any doctor and will give us access
to copies of any letters, reports and test results.
• Your medical report won’t ask for details of any negative tests for
HIV, hepatitis B or C. It won’t ask about any isolated or multiple
incidences of sexually transmitted diseases unless there are long
term health implications.
We may need to send your application and any medical report to our
reassurers or underwriting company for their opinion or to obtain their
agreement to the terms offered. We may also need to send them at a
later date in connection with the management of the plan. You can
get details of general reassurance principles and details of any
company we use to assess your application, from us at the address
shown below.
A doctor may choose to fax a medical report to us. The report may
also be faxed to our reinsurers. If a medical report indicates abnormal
findings or test results, we’ll inform your doctor. If you have any
questions about your rights under the Act or any questions about the
process of obtaining, assessing or storing medical information, please
write to us at:
Customer Services,
Tricentre One, New Bridge Square,
Swindon SN1 1HN.
Or call us on 01793 514514.
We are open from Monday to Friday 8.30am to 6pm
• Blood pressure readings in the last three years.
Any history of disease in your parents or siblings you’ve told your
doctor about.
Your medical report will not ask for any information about:
• negative tests for HIV, hepatitis B or C;
• isolated or multiple incidences of sexually transmitted diseases
unless there are long-term health implications; or
• genetic test results, unless there is a favourable test result that
shows you’ve not inherited a condition.
The information you and your doctor give us about your health may
result in insurance being declined, payments being increased above
standard rates or payments being set at standard rates.
29
Declaration
I/We have read the section headed ‘What are my access to medical reports rights?’. I/We consent to Zurich Assurance Ltd (Zurich) obtaining
medical information from any doctor about anything affecting my/our physical or mental health and to Zurich obtaining information from
other insurers about previous applications I/we have made for any life, sickness, accident or private medical insurance. I/We authorise those
asked for such information to provide it on the production of a copy of this consent.
I/We do/do not* want access to any medical report prepared as a result. (*delete as appropriate).
Plan number
Name of 1st life
Signature of 1st life
Date of signature
D D
M M
Y Y Y Y
Name of 2nd life
Signature of 2nd life
Date of signature
D D
Zurich Assurance Ltd
Registered in England and Wales under company number 02456671.
Registered Office: The Grange, Bishops Cleeve, Cheltenham, GL52 8XX.
Telephone 01793 514 514.
NP718286002 (11/15) RRD
M M
Y Y Y Y