• Submission Date
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    2 digit day, 2 digit month, 4 digit year
  • Do you currently subscribe to the Retired Officers Scheme?*

  • Main Member Details

  • Main member date of birth*
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    2 digit day, 2 digit month, 4 digit year

  • Section One

  • Date of birth*
     / /
    2 digit day, 2 digit month, 4 digit year
  • Sex*
  • Date joined force/service
     / /
    2 digit day, 2 digit month, 4 digit year
  • Do you currently subscribe to the Retired Officers Scheme?
  • Member number type or ID number
  • I confirm I have been actively at work in my usual occupation for a period of 8 consecutive weeks prior to my intended commencement of cover date (normal annual holiday entitlement may be ignored) and that I have not had more than 14 days absence through illness and/or injury during the last 12 months. Or, if you are unemployed, (applicable to Spouse/Partner only):- I confirm that I have been fully fit and active for a period of 8 weeks prior to my intended commencement of cover date and that I have not suffered from illness or injury for more than 14 days in total during the last 12 months.*
  • I confirm I am in good health and not aware of any condition or symptoms which may give rise to a claim under this insurance.*
  • Are you in receipt of any ongoing treatment or care (including check ups or regular medication) for any accident, illness or medical condition.*
  • Are you currently awaiting referral to a medical practitioner or specialist/consultant or are you awaiting the results of any tests or medical investigations?*
  • Have you had any application for insurance declined, postponed or subject to an increased premium or other special terms applied, or have you previously made any claims for Critical Illness or Sickness insurance?*
  • I understand that if this declaration is found to be untrue then my insurance will be invalidated and scheme membership cancelled with no return of premiums.*
  • I authorise the payroll department to deduct the appropriate subscription from salary.*
  • Has any application for life, income protection (P.H.I.) or critical illness insurance on your life ever been declined, postponed, withdrawn or deemed unacceptable at ordinary rates, or accepted at an extra premium, subject to a debt or other special terms? Please note this also includes any application to join this or any other insurance, individual or group scheme.*
  • Has any proposal for any form of insurance on your life been made to any insurance company within the past six months or are you expecting to do so in the next six months?*

  • Section Two

  • 2. Height unit?
  • 4. Weight unit?
  • 5. Has your weight changed in the last six months?
  • 8. Have you used any form of tobacco (including nicotine replacement) in the past 12 months?
  • 15. In the past 5 years have you been to your GP or any other medical professional for any form of medical consultation, investigation, treatment or advice or are you awaiting these? (For females please include cervical smears/mammograms as applicable).
  • 16. Have you ever consulted your GP or any other medical professional for Anxiety, Stress, Depression or any other mental illness?
  • 17. Have you EVER suffered from High Blood Pressure, Raised Cholesterol, Stroke, circulatory problems, brain haemorrhage or permanent brain injury?
  • 18. Have you EVER suffered from Any cyst, growth, tumour or cancer?
  • 19. Have you EVER suffered from Any form of kidney (renal) disease?
  • 20. Have you EVER suffered from Any disease or disorder of the eyes (not corrected by spectacle or lenses), ears, nose, throat or skin?
  • 21. Have you EVER suffered from Any disease or disorder of the respiratory system including Asthma, Bronchitis or Emphysema, chest/lung disorder, breathlessness?
  • 22. Have you EVER suffered from Any musculoskeletal disorder, including Back Pain, Sciatica, Whiplash, Rheumatism or Arthritis?
  • 23. Have you EVER suffered from Any disease/disorder of the digestive system, stomach, pancreas, liver including Gastric or Duodenal Ulcer, Irritable Bowel Disease, Colitis, Crohn’s Disease, Indigestion, Hiatus Hernia, Gout, Prostate, Bladder problems or Hepatitis?
  • 24. Have you EVER suffered from Diabetes?
  • 25. Have you EVER suffered from Multiple Sclerosis, Parkinson’s disease, paralysis, epilepsy, Alzheimer’s disease, dementia or cerebral palsy?
  • 26. Have you EVER suffered from heart attack, angina, heart disease?
  • 27. Have you ever suffered from any numbness, dizziness or any disease or disorder affecting your balance?
  • 28. In the last 5 years have you been exposed to the risk of HIV infection (note this can be caught through unsafe sex, Intravenous (IV) drug abuse, blood transfusions or surgery undertaken outside of the UK and EU)?
  • 29. Are you using or have you ever used drugs other than those prescribed by a doctor or obtained over the counter from a pharmacy? i.e. recreational drugs such as ecstasy, cocaine, heroin, etc?
  • 30. Do you anticipate any travel outside of the UK, Western Europe, North America or Australasia (other than for holiday)?
  • 31. Are you currently taking any medication?
  • 32. Have you tested positive for HIV/AIDS or Hepatitis B or C, or been tested/treated for other sexually transmitted diseases or are you awaiting the results of such a test?
  • 33. Have any of your parents, brothers or sisters died or suffered from heart disease, stroke, high blood pressure, diabetes, kidney disease, cancer, multiple sclerosis, nervous disorder or any hereditary disease before age 65?
  • 34. Do you currently, or do you intend, to take part in any hazardous leisure activities? (For example, Private Aviation, Motor Racing, Mountaineering)
  • 35. Have you had any operation, x-rays or special investigations?*
  • 36. Within the last 10 years have you lived for longer than 1 month in any country outside your normal country of residence, Western Europe, North America or Australasia?*

  • Section Three

  • IMPORTANT NOTES
    Please note that your answers to the questions on this form will be used to assess the risk involved in providing you with the proposed level of cover. If you are unsure whether a particular fact is important you should disclose it.

    Cover will not start until we have assessed and accepted your answers given in this form.

    We may ask you to contact your doctor to speed up the completion of reports that we have requested.

    If we ask you to attend a medical examination, it will be necessary for us to share your application information with another company authorised by us. They will make the arrangements for the examination to take place.

    It may be necessary for us to send your form and relevant medical reports to the participating Lloyd’s Underwriters or their Reassurers for their opinion or agreement of the terms offered.

    On occasion the faxing of medical reports may help to ensure a speedier assessment of your medical assessment. We only accept faxed information direct to a fax machine in a secure part of our building. This ensures that we maintain strict confidentiality. If you do not agree to allow the faxing of information, please indicate by deleting the appropriate section in this form.

    The Insurer has a confidentiality practice in place which means that your medical information is held securely and access is limited to authorised individuals who need to see it.

    You must inform us of any changes in your health or other circumstances during the period between this form being completed and in us notifying the terms on which cover will be offered.

    DATA PROTECTION

    I understand and consent to the use of any information provided by us for the operation of this insurance. This includes the process of underwriting, administration, claims management, rehabilitation and handling customer concerns.

    I understand that in order to do this the information may be shared with other insurers, re-insurers, insurance intermediaries and service and service providers who are involved in either the operation of insurance which covers employees or the employee benefits arrangements provided by the company.

    I understand the data will be processed fairly and securely in accordance with the Data Protection Act 1998 and the details will be stored on computer but will not be kept for longer than necessary.

    I confirm that data in relation to this insurance has been obtained and passed to insurers in accordance with the requirements of the Data Protection Act 1998.

     

    STATEMENT OF PRACTICE ON GENETICS
    In accordance with the Association of British Insurer’s (‘ABI’) policy on genetics and insurance, you do not need to tell us about any genetic test you have had if the proposed level of cover, taken together with any other insurance cover you already have, total:

    • £500,000 or less for life assurance.
    • £300,000 or less for critical illness or income protection.

    Above these limits, you may need to tell us about certain genetic test results when applying for certain types of insurance. We will only be interested in genetic test results which have been approved by the Government’s Genetic and Insurance Committee for insurers’ use.

    If you think this may apply to you, please ask us for details of the current position. These details are also available from the ABI website at www.abi.org.uk

    However you must tell us if you have either 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
    It may be necessary for us to obtain medical reports to support your application for cover. Before we can ask any doctor that you have consulted to complete a report, we need your permission under the Access to Medical Reports Act 1988. Your rights under the Act are as follows:

    • You can ask to see the report before the doctor returns it to us. If you do, we shall tell the doctor to retain the report for 21 days so that you can arrange to see it. If you have not made arrangements to see the report within this time, your doctor will send the report to us.
    • You do not have to give your consent, but if you do not we may be unable to proceed. This does not stop you from applying to other companies for insurance.
    • If you choose not to see the report at this stage, you may ask the doctor for a copy within 6 months of it being sent to us. A duplicate report can be sent to your doctor on request should you wish to see it at a later date.
    • If you consider any aspect of the report to be incorrect or misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him/her to attach a statement outlining your views, which will then accompany the report.
    • Your doctor can withhold access to the report if he/she feels that it would cause physical or mental harm to you or others.
    • Your medical report will contain details of relevant consultations, treatment, operations, investigations and test results that you have undergone at any surgery, hospital or clinic. Your consent will give the Insurer access to this information.
    • If you have any questions regarding your rights under the Act or any questions relating to the process of obtaining, assessing or storing medical information, please write to the Compliance Officer at our Head Office.
  • I wish to see the report before it is sent to the Insurer*

  • Section Four

  • DECLARATION
    Please sign this Personal Declaration once you have read it together with all of the sections. If you are unsure as to whether any information should be given, you should provide it. If you are applying for insurance with other companies at the same time, by signing the form you are consenting to copies of medical reports being sent to these other companies at their request. However, if we are approached by another company to provide copies of highly sensitive information we shall ask for your specific written permission before doing so.

    • I will inform you immediately of any changes that occur before the Insurer notify the terms on which cover will be offered. I understand that failure to do so may result in the loss or cancellation of the cover being assessed.
    • 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 form or are attached in a sealed Private and Confidential envelope, and are true and complete.
    • I agree to Insurer obtaining medical information from any doctor whom I have consulted about my physical or mental health, in order to assess my application. You may obtain relevant information from other insurers about previous or concurrent applications for life, critical illness, sickness, disability, accident or private medical insurance that I have applied for. I authorize those asked for such information to provide it on the production of a copy of this consent. This consent allows the Insurer to obtain medical reports at any time during the period of the cover or after my death to support any claim made on the cover proceeds.
      • This information can also be used to maintain management information for business analysis.
      • I agree that a copy of the agreement given in this Declaration will have the validity of the original.
      • I agree to the Insurer accepting medical reports faxed directly to the company from my doctor’s surgery. I also do not object to copies of the report being sent to any other company that I have applied to at their request.

    By signing this form I am allowing the Insurer to carry out my risk assessment using the information that I have provided. This information can also be used to process any claim made in respect of me on this policy.

    I confirm I have read and understood the information in this form including the section relating to:

    • Data Protection
    • Statement of Practice on Genetics
    • Access to Medical Reports Act 1988
    • The Declaration

    I understand that the Insurer may ask other insurers for information to check the information I have given.

  • Date of Signature*
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    2 digit day, 2 digit month, 4 digit year
  • Should be Empty: