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Aviva personal protection application and data capture form

Important informationIt is important that all questions are answered fully, truthfully and accurately. Please remember that we'll use the answers given to assess the terms and the extent of benefits we can offer. Even if information has already been provided in a previous application , it must be provided to us again as our systems may not identify the previous incorrect or incomplete information is provided this may result in the policy being amended or cancelled, may reduce the amount payable in the event of a claim, or may result in the non-payment of a have a confidentiality policy in place, which means we hold medical information securely and access is limited to authorised individuals who have a need to see personal protection application and data capture formHow to fill out this formYou can use this form as a paper application or as data capture . If you are using this as an application form you can apply for up to 6 contracts at once. There can be a maximum of two policyholders and two lives covered per application .

6 Life & critical illness premium basis Note 1 Guaranteed Reviewable Cover Cover amount Note 2 OR Premium Cover amount Note 2 OR Premium Term No. of years OR Until age Note 3 No. of years OR Until age Note 3 Please number the policies you apply for in the space provided as this may be needed in Sections 19 and 22(4).

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Transcription of Aviva personal protection application and data capture form

1 Important informationIt is important that all questions are answered fully, truthfully and accurately. Please remember that we'll use the answers given to assess the terms and the extent of benefits we can offer. Even if information has already been provided in a previous application , it must be provided to us again as our systems may not identify the previous incorrect or incomplete information is provided this may result in the policy being amended or cancelled, may reduce the amount payable in the event of a claim, or may result in the non-payment of a have a confidentiality policy in place, which means we hold medical information securely and access is limited to authorised individuals who have a need to see personal protection application and data capture formHow to fill out this formYou can use this form as a paper application or as data capture . If you are using this as an application form you can apply for up to 6 contracts at once. There can be a maximum of two policyholders and two lives covered per application .

2 Policyholders and lives covered don't have to be the same people unless applying for Income protection +. You should complete a separate product details section for each contract and number them for further use in the form, you may also want to send a copy of your quote with this form to: Aviva , PO Box 520, Norwich, NR1 note: Section 7 is an additional health questionnaire. You must complete this section if you answer yes to any question in Section 6, other than questions 1, 2 or asthma. Please complete an additional health questionnaire for each condition disclosed in Section 6. Section 9 is an additional family history questionnaire. You must complete this section if you answer yes to any question in Section 8. Please complete this section for each family history disclosed in Section 8. If you are using this for data capture , you do not need to send the form to us. If a declaration is required please ensure you return Section 20. Using Aviva s interactive underwriting by applying online is the most effective way to apply for our products, it also offers an uplift in before the contract comes into forceUntil we confirm when the cover will start you must notify us immediately of any change in the circumstances relating to the health, activities, occupation or residence of the person(s) covered which would change any of the answers or information provided in this application form.

3 This includes attending any medical appointment or consultation after submitting the changes may affect the terms and extent of the benefit we can offer. We reserve the right to offer amended terms or decline policies under trustData capture : If you are using this form for data capture and a policy is to be placed under trust, you can post the paper trust form(s) or complete the online trust at the point when inputting the application data. You will need to speak with the applicant(s) at the time of completing the trust details application : If you are using this form as a paper application and a policy is to be placed under trust, please complete an appropriate paper trust form(s). You can either return along with the application or at a later use: application Data captureContents1 Account information2 personal details3 Product details Life Insurance+ Product details Critical Illness+ Product details Income protection + Product details Whole of Life Insurance+4 Policyholder details5 Lifestyle 6 personal medical history7 Additional health questionnaire (needed for each condition disclosed in section 6)8 Family history9 Additional family history (needed for each condition disclosed in section 8)10 Residency, travel & sports11 Occupation12 Overall cover13 Doctor s details14 Payment details15 Important information16 Data protection17 Medical information18 Financial crime19 Declaration personal protection products20 Short financial questionnaire (needed if overall cover in the market exceeds 1,500,000 for life or 750,000 for critical illness and/or employee significant illness)21 AMRA consent form (if required)22 Spare policyholder details and additional health questionnaire pages (if required)

4 130/06/20 9:38 PMSection 1 Account informationWas advice given? Yes NoIndemnity commission Yes NoAdviser use For paper application onlyIf the application contains multiple policies and you don't want the same commission details for each policy, please give us the commission details on a separate paper including the associated number you have allocated to that policy in Section you're using this form as a paper application , we'll automatically put the policy pack in the post to your client(s). You may also want to send a copy of your quote with this initial commission onlyCommission type Required SacrificedCommission style Initial and renewal No commissionCommission basis Lautro points Percentage of entitlement Enter Lautro points Enter percentage of entitlement %Apply these commission details for all Yes NoContact email addressIntermediary Case Reference NumberFCA numberContact phone numberPanel IDCompany nameContact nameAccount codeAdviser 230/06/20 9:38 PMAdviser use For paper application onlyFor initial commission onlyFirst life coveredSecond life covered2.

5 NameLast nameMiddle nameFirst nameLast nameMiddle nameFirst name11. Pre-sale underwriting reference9. EmailSection 2 personal details1. Title8. Phone numberHomeMobileHomeMobile4. Gender Male Female Male Female5. Occupation7. Smoking, tobacco and nicotine useWe need accurate information about your client s use of cigarettes, cigars, a pipe or any other tobacco or nicotine products including nicotine gums, patches, inhalers, tablets, lozenges, sprays and electronic products, even if only on an occasional basis. It s an important factor in our assessment of terms and payment of claims. We may carry out tests to confirm used Regular, occasional or social useCompletely stopped within last 12 monthsCompletely stopped more than five years agoCompletely stopped more than three years agoCompletely stopped more than 12 months ago10. AddressThe policyholder (and life covered, if different), must be a resident of the UK, Channel Islands, Isle of Man or GibraltarCountyTown/CityPostcode Address line 1 Address line 2 CountyTown/CityPostcode Address line 1 Address line 2 First life coveredSecond life covered6.

6 What is your relationship to the first life covered?SpouseCivil partnerLive in partnerCo-mortgageeLender/Guarantor ( personal Loan protection )3. Date of 330/06/20 9:38 PMPlease number the policies you apply for in the space provided as this may be needed in Sections 20 and 23(4).Section 3 Product details: Life Insurance+Notes:Note 1: Premium basis applies to both livesNote 2: If you are applying for family income cover please give cover amount as annual amount, cover cannot be determined by premiumNote 3: Only available for single life policiesNote 4: Upgraded critical illness and extra care cover only available with life & critical illness coverNote 5: Upgraded children's benefit only available if at least one life has life & critical illness coverNote 6: Global treatment only available on one Aviva or Friends Life policy Note 7: Fracture cover only available on one Aviva policyNote 8: Total permanent disability option is only available with life & critical illness coverNote 9: Increasing cover is not available with conversion & renewal option or on decreasing coverNote 10: RPI is only available on level cover with the increasing cover optionNote 11: Conversion option only available with level life coverNote 12.

7 Renewal option only available with level life cover or level life & critical illness cover with guaranteed premiumsNo. No. Life coveredFirst life Second life Both First life Second life Both PolicyholderFirst policyholderSecond policyholderAs above First policyholderSecond policyholderAs above Family income cover Family income cover Level DecreasingPolicy interest rate % (4-15% to 2 decimal places)Cover typeWith critical illness First life Second life BothLevel DecreasingPolicy interest rate % (4-15% to 2 decimal places)With critical illness First life Second life BothLife & critical illness premium basis Note 1 Guaranteed ReviewableGuaranteed ReviewableCoverCover amount Note 2 OR Premium Cover amount Note 2 OR Premium TermNo. of years OR Until age Note 3 No. of years OR Until age Note 3 Please number the policies you apply for in the space provided as this may be needed in Sections 20 and 23(4).

8 Section 3 Product details: Life Insurance+ 430/06/20 9:38 PMNo. of years OR Until age Note 3 Please number the policies you apply for in the space provided as this may be needed in Sections 20 and 23(4).Section 3 Product details: Life Insurance+ continuedNo. No. If yes, give existing Aviva or Friends Life policy number(s)Will this replace an existing Aviva or Friends Life policy?Yes NoYes NoOptions Upgraded critical illness Note 4 First life Second life Both Upgraded critical illness Note 4 First life Second life Both Upgraded children's benefit Note 5 Upgraded children's benefit Note 5 Extra care cover Note 4 First life Second life Both Extra care cover Note 4 First life Second life Both Global treatment Note 6 First life Second life Both Global treatment Note 6 First life Second life Both Fracture cover Note 7 First life Second life Both Fracture cover Note 7 First life Second life Both Conversion Note 11 Renewal Note 12 Conversion Note 11 Renewal Note 12 Increasing cover Note 9 Increasing cover rate 3% 5% RPI Note 10 Increasing cover Note 9 Increasing cover rate 3% 5% RPI Note 10 Total

9 Permanent disability Note 8 First life Second life Both Total permanent disability Note 8 First life Second life Both Waiver of premium First life Second life Both Deferred period first life 1 month 3 months 6 months Deferred period second life 1 month 3 months 6 months Waiver of premium First life Second life Both Deferred period first life 1 month 3 months 6 months Deferred period second life 1 month 3 months 6 530/06/20 9:38 PMLife & critical illness premium basis Note 1 Guaranteed Reviewable Guaranteed Reviewable CoverCover amount Note 2 OR Premium Cover amount Note 2 OR Premium TermNo. of years OR Until age Note 3 No. of years OR Until age Note 3 Please number the policies you apply for in the space provided as this may be needed in Sections 20 and 23(4).Section 3 Product details: Life Insurance+No. No. Life coveredFirst life Second life Both First life Second life Both PolicyholderFirst policyholderSecond policyholderAs above First policyholderSecond policyholderAs above Family income cover Family income cover Level DecreasingPolicy interest rate % (4-15% to 2 decimal places)Cover typeWith critical illness First life Second life BothLevel DecreasingPolicy interest rate % (4-15% to 2 decimal places) With critical illness First life Second life BothNotes:Note 1: Premium basis applies to both livesNote 2: If you are applying for family income cover please give cover amount as annual amount, cover cannot be determined by premiumNote 3: Only available for single life policiesNote 4: Upgraded critical illness and extra care cover only available with life & critical illness coverNote 5.

10 Upgraded children's benefit only available if at least one life has life & critical illness coverNote 6: Global treatment only available on one Aviva or Friends Life policy Note 7: Fracture cover only available on one Aviva policyNote 8: Total permanent disability option is only available with life & critical illness coverNote 9: Increasing cover is not available with conversion & renewal option or on decreasing coverNote 10: RPI is only available on level cover with the increasing cover optionNote 11: Conversion option only available with level life coverNote 12: Renewal option only available with level life cover or level life & critical illness cover with guaranteed premiumsSection 3 Product details: Life Insurance+ continuedPlease number the policies you apply for in the space provided as this may be needed in Sections 20 and 23(4). 630/06/20 9:38 PMSection 3 Product details: Life Insurance+ continuedNo. No. Please number the policies you apply for in the space provided as this may be needed in Sections 20 and 23(4).


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