Personal Protection. Application/Data Capture form. How Advisers can use this form. Application reference number

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Personal Protection

Application/Data Capture form

How Advisers can use this form

a) Data capture form for online submission

• Submitting your application online at pruprotect.co.uk means that you can have an immediate underwriting decision or details of other information required. • Complete to the end of section J and also collect the Direct Debit details on

page 33 to submit online.

• Your client(s) must sign the Access to Medical Reports Act Declaration on page 31. Detach this declaration ONLY and post it to: PruProtect, New Business, Stirling, FK9 4UE

OR

b) Tele-underwriting data capture (not available for Essentials Plan).

• Complete sections A-D. Your client(s) must sign the Access to Medical Reports Act Declaration on page 31, the Direct Debit instruction on page 33.

• Post the paper application to the address above. OR

c) Paper submission (not available for Essentials Plan). • Complete all sections.

• Your client(s) must sign the Access to Medical Reports Act Declaration on page 31, the Direct Debit instruction on page 33 and the client declaration, authority and consent starting on page 35.

• Post the paper application to the address above.

Contents

Adviser information... A - The Life(s) Assured ... B - Core benefits... C - Plan details... D - Cover options... - Life Cover... - Serious Illness Cover... - Protect your cover... - Optional Serious Illness Cover for

Children... - Income Protection Cover... - Health Cover... - Family Income Cover... - Education Cover... - Disability Cover... - Waiver of Premium... E - Lifestyle details... F - Doctor/clinic details... G - Confirmation schedule details... H - Sports and pastimes supplementary

questionnaire... I - Medical questionnaire disclosure... J - Plan start date... K - Access to Medical Reports Act... L - Direct debit details... M- Full paper application client

declaration... Next steps in the application process...

3 4 6 7 8 8 8 9 9 10 12 13 14 15 16 17 24 24 25 26 30 30 33 35 38 Colour key

Core application section to complete Extra cover options to complete if applicable

IMPORTANT INFORMATION: You can only apply for the PruProtect Essentials Plan online at pruprotect.co.uk. Collect the information required using this form and then submit the application online.

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Look out for this symbol, which highlights important guidance notes or instructions throughout the form.

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Please use black ink, BLOCK LETTERS and tick or complete answers as appropriate. Please help us by filling in the application form honestly and in full. If you miss any information out, or give us misleading information, this is likely to mean that a future claim will not be paid. In addition, this could also delay the processing of your application. If you are uncertain about whether any particular fact would influence our decision, you should include it. If you do not, it is likely that a claim in the future will not be paid. Please disclose all relevant information as we may not contact or obtain a GP report.

If someone else fills this form in for you (for example, your Financial Adviser), please check that all the details are correct before you sign the declaration. You are responsible for all the answers you or your Financial Adviser provide on this application. If you make a mistake please cross it out, put in the correct word or words and initial next to the correction.

If you would prefer, you may complete the medical questions in private and return the Lifestyle details section direct to our Chief Medical Officer. Please indicate on this form if you have done so.

It is very important that you tell us if there is a change to any of the following between completion of this form and your application being accepted.

If you do not, the plan may be cancelled and will result in non-payment of a claim. Information about genetic tests.

If this application, taken together with any other insurance policies you already have, is for Life Cover up to a sum of £500,000 or Serious Illness/Critical Illness Cover up to £300,000 you need not disclose any genetic test you may have had. You need not disclose the result of any genetic test undertaken in the context of research. Genetic test results need only be disclosed where the sum exceeds either £500,000 for Life Cover or £300,000 for Serious Illness/Critical Illness Cover and their use by insurers has been independently approved. You may, of course, disclose any genetic test result which is in your favour. If you either have a family history of, are experiencing symptoms of, or are having treatment for, a genetic condition, you must tell us.

Further information is available on request which fully explains this policy and details those genetic tests approved for use by insurers.

Failure to disclose relevant information may result in non-payment of a claim.

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• your personal health

• your family history

• your occupation

• your participation in any hazardous leisure activities

• your travel or residence

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PruProtect agency number 3.Commissions 2.Agencydetails

FinancialAdvisertocompleteallquestionsonthispage

Adviserinformation

1.FSARegulatoryNo OR *OtherUK/EURegulator AND Registered Individual’s first name

Registered Individual’s surname

1 2 3 4 6 X

4.Policycorrespondence

Direct to Owner with copy to you

Plandocumentsto:

Both to you

Direct to Owner with copy to you Both to you

Acceptanceletter

Percentage of commission discounted (rebated) . %

5.Wasadvicegiven?

Yes No

Disclose commission on illustration Yes No

6.Marketingchoice

We would like to keep your client updated with information on our and other carefully selected providers, products and services which we think might be of interest by telephone, post, email or text. If your client would prefer not to receive this information please tick this box.

when submitting online.

Important - If applying for Health Cover, you can only choose for the acceptance letter and plan documents to be sent direct to the owner with a copy to you.

er in fo rm at io n

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DID YOU KNOW: YouhavethechoicetoreceiveyourcorrespondencefromPruProtectelectronically,viaa secureinbox.SimplylogontotheIntermediaryZone,goto‘Profiledetails’then‘Applicationalertsand communicationpreferences’andselectyourpreferredcorrespondenceoption–eitherelectronicorpost.

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First name(s) Surname Mr Mrs Ms Other Current address Postcode Male Female Gender Date of birth D D M M Y Y Y Y Telephone (home) Telephone (work) Mobile Email address

If this is a joint application, the First Life Assured must be the person selecting the highest level of Life Cover. If no Life Cover is selected, then the First Life Assured is the person with the highest level of Serious Illness Cover. If there is no Life Cover and no Serious Illness Cover selected, then the First Life Assured is the person with the highest level of Income Protection Cover. If both lives choose the same level of cover, the First Life Assured will be the first person on the application.

First name(s) Surname Mr Mrs Miss Ms Other Current address Postcode Male Female Gender Date of birth Telephone (home) Telephone (work) Mobile Marital status (please select one option only)

Single Separated

Married Civil partner

Dissolved civil partnership Divorced

Widowed Surviving partner_{of civil partnership}

A . C lie nt Miss D D M M Y Y Y Y

Marital status (please select one option only)

Single Separated

Married Civil partner

Dissolved civil partnership Divorced

Widowed Surviving partner_{of civil partnership}

Email address 4 Failuretodisclose relevantinformation mayresultinnon-paymentofaclaim.

First (or only) Life Assured Second Life Assured (if applicable)

A . Th e Li fe (s )

Preferred contact number (please select one option)

What time of day would you prefer we contacted you?

Home Work Mobile

Preferred contact number (please select one option)

Home Work Mobile

What time of day would you prefer we contacted you?

Policycorrespondence

We will send you correspondence regarding your policy by email, or via a secure online inbox located on our Member Zone (pruprotect.co.uk/member). To allow us to do so please supply your preferred email address.

If you do not want to receive your policy correspondence electronically please tick the 'post only' box below. Post only

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£

If ‘Yes’ please state the type of cover and the total sum assured you are covered for.

2. Do you have any Serious Illness/Critical Illness Cover or Income Protection Cover with any other companies including any you are currently applying for?

Income Protection Cover

each month £

Yes No

1. Do you already have any Life Cover, Serious Illness/Critical Illness Cover or Income Protection Cover with Prudential, PruProtect or Scottish Amicable?

Contract number(s) Contract number(s)

3. Do you intend to cancel any of the insurance cover (excluding Life Cover) outlined in questions A1 and A2 above when your PruProtect plan starts?

Income Protection Cover each month

Yes No

Yes No Yes No

If ‘Yes’ please provide full details of type of cover and amount being cancelled.

4. Have you ever been accepted at special terms or refused cover by any other insurance company for Life Cover, Serious Illness/Critical illness Cover or Income Protection Cover?

Yes No Yes No

If you answered ‘Yes’, please provide details If you answered ‘Yes’, please provide details £

Serious Illness/

Critical Illness Cover £

Serious Illness/ Critical Illness Cover

£ Income Protection Cover

each month £

Income Protection Cover each month

£ Serious Illness/

Critical Illness Cover £

Serious Illness/ Critical Illness Cover

L ife (s ) A ss ur ed Failuretodisclose relevantinformation mayresultinnon-paymentofaclaim.

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Surname First name(s)

Mr Mrs Miss Ms Other

Address for correspondence

Postcode

Telephone (home) Telephone (work)

Mobile Email address

Relationship to life/lives assured Reason for assurance

Thissectionmustbecompletedbyallapplicants. 5. Who is the owner of the policy? (please tick one box)

5.1 the First or only Life Assured 5.2 both lives

5.3 the following party Trust(ee)

(Go to section B below) (Go to section B below)

(Complete the details below where appropriate)

B.Corebenefits

If only Income Protection Cover has been selected, please go to question C7 and then section D5.

1. Start building your Plan by choosing at least one or more of our core benefits. Life Cover

Serious Illness Cover

Income Protection Cover

6 B . C or e b en ef it s A . Th e Li fe (s CoverBooster

Get 30% extra Life Cover free for three years. To qualify you need:

• Maximum entry age of 55 next birthday

• Life Cover with a minimum plan term of 15 years • A minimum of £20,000 of Serious Illness Cover

Terms and conditions apply - the 30% free Life Cover amount will be capped at £150,000. (Subject to meeting certain underwriting requirements.)

SPECIA

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SPECIA

L

OFFER

1. What amount do you want for your Plan Account? £

2. Do you require your Plan Account to be set up on a fixed term or Whole of Life basis?

4. PlanAccountbasis

Do you want your Plan Account and Disability Cover to be: Fixed term

Guaranteed

Indexed OR Level OR Decreasing 3. Plandetails

Reviewable

years 3.1 What term do you want for your Plan Account?

(The minimum term is 5 years. Leave blank for Whole of Life plans)

6. IsthisPlantobeusedinconnectionwithamortgage?

Yes – existing or other mortgage No Yes – new mortgage

3.2 Do you want your premiums for benefits linked to the Plan Account and Disability Cover to be guaranteed or reviewable?

(A decreasing Plan Account basis is not available for Whole of Life Plans)

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If you choose for cover to be Indexed, you could pay the same premium (for those covers that you index) in the first year as with Level cover. With Indexed cover, at each policy anniversary you can choose to increase cover by RPI - by doing so premiums will increase by RPI + 2.5%.

5. Accelerator

5.1 The Accelerator allows you to select a lower premium at the outset which will increase annually by 3%. Do you require the Accelerator option?

7. Vitality

With our Vitality programme, all members get discounts with our health partners. Available at an extra premium, Vitality Plus makes being healthy even more rewarding with additional discounts with our reward partners and enhanced gym membership discounts.

5.2 How long do you want your premiums to increase for?

Yes No

Full term 10 years

Do you require Vitality Plus?

Yes No

Whole of Life

8. CoverBooster

If your Plan qualifies, after three years there will be a premium charged for Cover Booster. We will advise you before the end of the three years what this amount will be.

Do you want th e Cover Booster amount to continue automatically at the end of three years, or would you like to inform us at the end of the three years whether Cover Booster should continue?

Yes, I would like the Cover Booster amount to automatically be added to my plan No, I will inform you if I wish to continue the plan with Cover Booster

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IfyouhaveselectedthePlanAccounttobesetuponadecreasingbasis,thencoveroptionsD1,D2,D9 musthavethesametermasthePlanAccount.

Do you require this benefit?

No Yes

Do you require this benefit? 1. LifeCover

If ‘No’ go to section D2.

No

Yes (If ‘No’ go to section D3)

2.1 Serious Illness Cover amount required? Complete as a monetary amount or percentage of the Plan Account.

2.3 What term is required for Serious Illness Cover?

2.4 What term does the Second Life Assured require? 2.2 What type of Serious

Illness Cover do you require?

Primary Comprehensive

Same term as Plan Account in section C

years

To age 70 exactly OR

OR

Same term as Plan Account in section C

years

To age 70 exactly OR

Same term as Plan Account in section C OR OR years To age 70 exactly OR OR £ % .

Questions 2.3 and 2.4 relate to the term required for Serious Illness Cover. If the Plan Account is set up on a decreasing basis do not complete and go to section D3. If the Plan Account is set up on a level or indexed basis, please complete question 2.3 if Life Cover has been selected OR please complete question 2.4 if Life Cover has not been selected. Pleasecompleteonequestiononly.

£

(This cannot exceed 100% of your Plan Account).

8 OR £ % of Plan Account .

1.2 What term does the Second Life require (if applicable)? You do not need to complete this question if the Plan Account is set up on a decreasing basis.

1.3 For a joint policy, do you require Life Cover to be paid on the first or the second death?

Same term as Plan Account in question C

OR _years

Second Life Assured (if applicable) 1.1 Life Cover for the First Life will be the amount of the Plan

Account in question C1.

What cover amount do you require for the Second Life (if applicable).

Complete as a monetary value or percentage of the Plan Account.

First death 2.SeriousIllnessCover

% .

(This cannot exceed 100% of your Plan Account).

OR Second death D .C ov er o pt io ns D . C ov er

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4. OptionalSeriousIllnessCoverforChildren(onlyavailableifLifeCoverorSeriousIllnessCoverhave beenselected.ThisoptionisnotavailableonadecreasingPlanAccount).

No Yes

Do you require this benefit? (If ‘No’ go to section D5)

3.Protectyourcover

Yes No

Do you want your Serious Illness Cover (and Life Cover if selected) to be topped up following a Serious Illness Cover claim?

3.1 Minimum Protected Account option

Percentage of Plan Account to be topped up (25% - 100%)

3.2 Protected Life Cover option (not available if Minimum Protected Account has been selected) Do you want your Life Cover only (if selected) to be topped up following a Serious

Illness Cover claim? Yes No

%

If you want to cover more children, please continue on a separate sheet. 4.1 Optional Serious Illness Cover for

Children required? Complete as a monetary amount or percentage of the Plan Account.

(This cannot exceed 100% of your Plan Account. The amount of cover applies to each child)

4.3 Please provide details of children to be covered.

First name(s) Surname Gender Date of birth

M F M F M F M F

4.2 What type of Serious Illness Cover do you want for Optional Serious Illness Cover for Children?

Primary OR Comprehensive OR £ % . D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y Child 1 2 3 4 er o p tio ns

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5.IncomeProtectionCover

Do you require this benefit? Yes No (If ‘No’ go to section D6)

5.1 What type of Income Protection Cover do you require?

The maximum amount of benefit that each applicant can choose is:

• Primary Income Protection Cover - the monthly equivalent of 50% of your earnings. This is subject to an overall maximum benefit of £10,000 per month

• Comprehensive Income Protection Cover - the monthly equivalent of 60% of the first £30,000 per annum of your earnings and 50% of earnings in excess of £30,000 per annum. This is subject to an overall maximum benefit of £16,666.67 per month

If you have been self-employed for less than one year your maximum benefit may be restricted.

5.3 What initial deferred period

do you require? _{7 days (self-employed only)}

5.4 What amount of monthly benefit do you require after the initial deferred period?

Primary Comprehensive

Primary Comprehensive 5.2 Do you wish to split your

cover over two deferred

periods? Yes No Yes No

1 month 3 months

6 months 12 months

7 days (self-employed only) 1 month

3 months

6 months 12 months

£ £

5.5 What additional deferred

period do you require? 1 month

3 months

6 months 12 months 5.6 What additional amount of

monthly benefit do you require after the additional deferred period?

£ £

PruProtect Essentials Plan - Data capture form 9 1 month

3 months

6 months 12 months (Choose one option only)

(Choose one option only)

10

First (or only) Life Assured Second Life Assured_{(if applicable)}

D .C ov er o pt io ns D . C ov er

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£ £ 5.10 If you make a claim do you

want your benefit

amount(s) during claim to:

Remain level

Increase in line with RPI Increase in line with RPI +2% (Available with Comprehensive Cover only)

Remain level

Increase in line with RPI Increase in line with RPI +2% (Available with Comprehensive Cover only)

5.11 Do you want your premiums for Income Protection Cover to be guaranteed or reviewable? Guaranteed Reviewable Guaranteed Reviewable 5.IncomeProtectionCover-continued 5.7 Do you want us to guarantee the earnings that we use to calculate your maximum monthly benefit? For more details please see your Policy Document.

Yes No Yes No

The following information will be requested from you during the underwriting process:

• If you are employed we require your three most recent payslips and P60.

• If you are self-employed we require your three most recent HMRC tax computations and Self Assessments together with a copy of the accounts that relate to these.

• If you are a director of a Limited Company we require your three most recent payslips , P60 and a copy of your most recent company accounts as submitted to HMRC, and advise how many employees work in the company.

5.9 Do you want your monthly benefit amount(s) selected above to increase in line with RPI (when not claiming)? Yes No Yes No years Or To age 60 exactly To age 65 exactly To age 70 exactly years Or To age 60 exactly To age 65 exactly To age 70 exactly

each month for _______ months, followed by

5.12. At what level and for how long would your earnings continue from employment if you are unable to work due to sickness or accident? This may affect any benefit you receive from us. For more details please see your Policy Document.

£

each month for _______ months, followed by

£

each month for _______ months each month for _______ months 5.7 What term do you require?

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6.HealthCover

6.1. Do you require this benefit? Yes No (if ‘No’ go to section D7)

6.2. What level of cover do you require? Heart and Cancer Cover Primary Cover

Comprehensive Cover 6.3. What hospital network do you require? Local

National London Premier 6.4. If you have chosen Serious Illness Cover

do you want to link your Health Cover to the Serious Illness Cover? This is known

as the Health Cover Optimiser option. Yes No

6.6. Please provide details of children under 18 years to be covered?

First name(s) Surname Gender Date of birth

M F M F M F M F Child 1 2 3 4

If you want to cover more children, please continue on a separate sheet.

6.5. Please provide details if you want your partner to be covered. (If you are applying for a joint Life Plan, the Second Life on the Plan will also be covered by Health Cover and their details should be entered here). Mr Mrs Miss Ms Other Forename(s) Surname D D M M Y Y Y Y Date of birth M F Gender 12 D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y D D M M Y Y Y Y D .C ov er o pt io ns D . C ov er F M

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On death or terminal illness On death, terminal

illness or serious illness

illness or serious illness 7.FamilyIncomeCover

7.1 Do you require this benefit? If ‘No’ go to section D8.

7.2 What type of Family Income Cover do you require?

7.3 Family Income Cover monthly amount required?

Yes No Yes No

£ £

7.4 Do you require own term or account term?

7.5 Do you want your cover to be indexed?

7.6 Do you want your premiums for Family Income Cover to be guaranteed or reviewable?

7.8 When would you like Family Income Cover to be paid?

7.7 What guaranteed payment term is required for Family Income Cover?

Primary

Comprehensive

Primary

Comprehensive

Own term years OR

Account term

Own term years OR

Account term Yes (in line with RPI)

No

Yes (in line with RPI) No Guaranteed Reviewable Guaranteed Reviewable 1 year / 2 years 5 years 10 years 1 year / 2 years 5 years 10 years er o p tio ns

The standard payment term is 1 year for Primary Cover and 2 years for Comprehensive Cover. You can also choose 5 or 10 years.

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8.EducationCover

First name(s)

Select type of school: (tick one)

Surname Gender Date of birth

M F Child 1 2 3 4 D D M M Y Y Y Y

8.1 Do you require this benefit? If ‘No’ go to section D9.

8.2 When would you like this benefit to be paid?

Yes No Yes No

8.3 Please provide details of children to be covered.

(severity level A)

State school Private school

with boarding Private day school

Select type of school:

(tick one) State school Private school with boarding Private day school

M F D D M M Y Y Y Y M F D D M M Y Y Y Y M F D D M M Y Y Y Y D .C ov er o pt io ns D . C ov er

First (or only) Life Assured Second Life Assured_{(if applicable)}

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9. DisabilityCover(onlyavailableifLifeCoverorSeriousIllnessCoverhavebeenselected)

9.1 Disability Cover amount required?

9.2 What type of Disability Cover do you require?

If the Plan Account is set up on a decreasing basis, do not complete question D9.3 and go to section D10. Question D9.3 also applies to a Plan Account set up on a Whole of Life basis. 9.3 What term do you require?

Level 1

Level 3 Level 2

If your Plan Account has been set up on a fixed term basis, the same term as Plan Account in section C To age 65 exactly To age 70 exactly OR Level 1 Level 3 Level 2 years OR

Do you require this benefit? Yes No (If ‘No’ go to section D10).

£ £

Expiry age

Own term OR

Account term

If your Plan Account has been set up on a fixed term basis, the same term as Plan Account in section C To age 65 exactly To age 70 exactly OR years OR Expiry age Own term OR Account term er o p tio ns

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In the event of a claim, the benefits we pay under any of the Waiver of Premium options below will cover all Plan premiums for the First and Second Life Assured (if applicable).

10.1 Do you require Waiver of Premium on Death? (This benefit is only available on joint life Plans, where Life Cover isn't the only benefit. In addition you are also required to have selected Life Cover or Serious Illness Cover).

Yes No

10.2 Do you require Waiver of Premium on Serious Illness?

Yes No

(This benefit is not available if Life Cover and/or Serious Illness Cover at 100% are the only benefits selected. In addition you are also required to have selected Life Cover or Serious Illness Cover). 10.3 Do you require Waiver of

Premium on Incapacity? (If Comprehensive Income Protection Cover has been selected then Waiver of Premium on Incapacity is also required).

10 .4 Deferred period required. (Choose one option only).

Yes No Yes No

1 month 3 months 6 months 12 months

1 month 3 months 6 months 12 months 7 days (self-employed only) 7 days (self-employed only)

16 16 D .C ov er o pt io ns D . C ov er

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If ‘Yes’, please detail the main manual or physical tasks you do, starting with the task you do the most and specify the percentage of your day spent doing this task.

(v) Does your occupation involve any form of manual or physical activity (including, but not limited to, lifting and carrying or standing for long periods)?

Yes No Yes No Task % of day % % % % Task % of day % % % % 3. (i) What is your main occupation?

Yes No Yes No

2. Have you smoked or used any tobacco products in the past 12 months? (Includes cigarettes, cigars, pipe, loose tobacco and any nicotine replacement therapy).

Wewillcarryoutrandomteststoconfirmnon-smokerstatus Weight

Height Height Weight

Waistsize Waistsize

1. What is your height, weight and waist measurement? You should give your exact measurements (imperial or metric), so if you are unsure of these please check.

(iv) Do you work less than 16 hours per week? If you are unemployed, a student, a houseperson, retired or a pensioner then answer ‘No’ to this question.

Yes No Yes No

(iii) Are you a member of the armed forces, territorial army or a reservist?

Yes No

If ‘Yes’, please provide the reason for cover, current location, future orders and details of duties and activities.

Yes No

If applying for Life Cover only go to section E4.

(ii) What is your total gross annual earnings for the current year?

£ £ st yle d et ail s

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NOTETOADVISER: Whensubmittingthe applicationonline,at thispointyouwill bepromptedto enterthePlanholder’s directdebitdetails whichyoucanfind onpage33. NOTE: Failuretodisclose relevant information mayresultinnon-paymentofaclaim. Pleasedonot assumethatwewill contactorobtaina reportfromyour doctor.

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If ‘Yes’, please give full details i.e. type of machinery/tools and % of day spent using machinery/tool. (x) Does your occupation involve working with any form of machinery or tools?

Yes No Yes No

If ‘Self-employed’, have you been in your present occupation for less than two years? (xi) What is your current employment status?

Employed

Yes No Yes No

If ‘Yes’, please provide details of how long you have been self-employed and details of your previous occupation. If ‘Yes’, please give full details including any use of explosives, qualifications held, exactly where the

underwater work takes place, and the reason for being underwater e.g. cable laying, research etc: (viii) Does your occupation involve any work underwater?

Yes No Yes No

If ‘Yes’, please give full details including any use of explosives. (vii) Does your occupation involve any work underground?

Yes No Yes No Self-employed Unemployed Employed Self-employed Unemployed If ‘Yes’, please give full details i.e. maximum height at which you work.

(vi) Does your occupation involve any work at heights over 40 feet?

Yes No Yes No

(ix) Does your occupation require you to travel more than 25,000 miles per annum by road? (Excludes commuting to and from your home to a fixed place of work).

E. L if es ty le 18

First (or only) Life Assured Second Life Assured (if applicable) Failuretodisclose relevantinformation mayresultinnon-paymentofaclaim. Where‘Yes’is answered,please providedetails.

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4. Have you in the last 5 years or do you intend to:

(i) Take part in any sport or pastime which involves any additional risk of accident? E.g. aviation, motorsports, climbing, diving, horse riding, martial arts or winter sports. You do not have to include football or rugby.

(ii) Take a holiday outside the UK lasting more than 3 months or live or work outside the UK for any period of time?

If‘Yes’,pleaseprovidefulldetailsusingthesportsandpastimesquestionnaireonpage25

Yes No Yes No

If ‘Yes’, please provide full details including exact area and country, dates, nature of visit along with details of any future travel planned.

No

5. (i) Do you or have you in the past 5 years ever regularly consumed more than 30 units of alcohol per week. 1 unit = 25 ml of spirits or a small (125ml) glass of wine or 1/2 pint of beer, lager or cider.

(ii) Have you been hospitalised, received inpatient treatment or had an implant to help you stop drinking? If ‘Yes’ please provide full details of the treatment received, dates treatment started and stopped and whether you still participate in follow-up appointments.

Yes Yes No

No

Yes Yes No

No

(iii) Have you ever taken recreational drugs such as cannabis, ecstasy, cocaine, heroin, anabolic steroids or similar substances in the last 10 years? (Ignore any drugs prescribed by a doctor or bought over the counter at a chemist).

Yes Yes No

If ‘Yes’, please provide details If ‘Yes’, please provide details

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No Yes

6. Have you ever tested positive for HIV, Hepatitis B or C, or are you awaiting the results of such a test? Note: If the result is negative, the fact of having a HIV test will not, in itself, have any effect on your acceptance terms for insurance.

If ‘Yes’, please give full details, including nature and date of test.

ThisinformationmaybesentinconfidencedirecttoourChiefMedicalOfficer.

(iii) Stroke or transient ischaemic attacks, brain haemorrhage or permanent brain injury through accident? 7. Have you ever had any of the following:

(ii) Heart disease or disorder – including heart attack, angina, heart murmur, cardiomyopathy, heart valve defect or heart surgery?

(i) Cancer, leukaemia, Hodgkin’s disease, lymphoma, brain or spinal tumour? No Yes Yes No No Yes Yes No No Yes Yes No No Yes Yes No

(v) Disease or disorder of the blood vessels – including circulation problems in the legs? No

Yes Yes No

No

Yes Yes No

(vi) Diabetes or sugar in the urine?

No

Yes Yes No

(vii) Mental illness that has required hospital treatment or referral to a psychiatrist or other specialist? Ifyouanswer‘Yes’toanypartofquestions7–12,thenpleasecompletethemedicalquestionnaire(s) beginningonpage26foreach‘Yes’answer.

(iv) Multiple sclerosis, optic neuritis, epilepsy, paralysis, muscular dystrophy, Parkinson’s disease, dementia, Alzheimer's disease, cerebral palsy, motor neurone disease or any other disorders of the brain or nerves?

No

Yes Yes No

(viii) Rheumatoid arthritis, Ankylosing spondylitis or any spinal surgery?

No

Yes Yes No

(ix) Do you suffer from continuous fatigue or tiredness?

E. L if es ty le 20

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8. In the last5years have you had any of the following:

(i) A lump or growth of any kind; or any mole or freckle that has bled, become painful, changed colour or increased in size? No Yes No Yes No Yes No Yes

(ii) Chest pain, irregular heart beat, raised blood pressure or raised cholesterol?

(iv) Seizure, fits, fainting or blackouts?

No Yes

(iii) Numbness, tremor, tingling, facial pain, visual disturbance including blurred vision, double vision or dizziness?

No Yes

(v) Any disorder of the digestive system, liver, stomach, pancreas or bowel – including gastric or duodenal ulcer, hepatitis, colitis or Crohn’s disease?

No Yes No Yes No Yes

(vi) Any disorders of the kidneys, bladder or prostate – including blood or protein in the urine or urinary tract infections?

No Yes

(viii) Any form of mental illness including anxiety, depression, stress, nervous breakdown or eating disorders? No Yes No Yes No Yes

(vii) Any sexually transmitted disease?

(x) Any disorder of the adrenal, pituitary or thyroid glands?

No Yes

(xi) Any disorder of the lungs or respiratory system – including asthma or bronchitis? No Yes No Yes No Yes

(xii) Any pain or problem relating to your back, neck, joints, bones or muscles including arthritis, slipped disc, rheumatism or gout?

(ix) Blood disorder or anaemia?

If applying for Life Cover only go to section E9

First (or only) Life Assured Second Life Assured (if applicable) Failuretodisclose

relevantinformation mayresultinnon-paymentofaclaim.

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10. In the last 5 years have you been offwork for 2weeksormore for any medical condition, illness or injury not already mentioned?

No Yes

12. In the last 6 months have you taken or been prescribed drugs, medicines, tablets or any other form of treatment? (Over the counter medication and oral contraception can be disregarded).

No Yes

11. Are you aware of any other medical condition or symptoms where you intend to seek medical advice or are you waiting for the results of any medical investigation?

(i) Undergone or been advised to have any investigation, x-ray, scan or blood test for any condition not already mentioned?

No Yes

(ii) Received any form of medical attention, including any surgical procedures at a hospital, for any condition not already mentioned?

No Yes No Yes No Yes No Yes

(xvi) Any gynaecological disorder (including abnormal cervical smears) or breast condition for which you have been referred to a specialist or required investigations or treatment?

No Yes

(xv) Disorder of the ears including difficulty hearing?

9. In the last 5 years have you: No Yes

(xiii) Disorder of the eyes including blindness or problems with sight – you can ignore sight problems fully corrected by glasses or contact lenses?

(xiv) Any disease of skin, i.e. psoriasis, dermatitis?

If applying for Life Cover only go to section E13.

(xvii) Only answer this question if you are applying for Health Cover.

Have you had any dental disorders such as over or underbite, missing or skew teeth, false teeth or ongoing treatment? No Yes No Yes E. L if es ty le 22

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FirstLife– If ‘Yes’, please complete this table

SecondLife– If ‘Yes’, please complete this table.

Relative Currentageof relative Ageof relative at diagnosis Medicalcondition(s).Ifcancerpleasestate whichpartofthebodyis/wasaffected Ageat death(if applicable)

13. Did either of your parents, or any siblings, suffer or die before the age of 65 from any of the following: (If you do not know the medical history of your natural parents or siblings then please answer ‘No’).

•Cancer

•Heart disease, stroke or diabetes

•Multiple sclerosis or Alzheimer’s disease

•Muscular dystrophy, Parkinson’s disease, motor neurone disease or haemochromatosis

•Huntington’s disease, polycystic kidney disease or polyposis of the colon

No

Yes Yes No

Relative Currentageof relative Ageof relative at diagnosis Medicalcondition(s).Ifcancerpleasestate whichpartofthebodyis/wasaffected Ageat death(if applicable)

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1. Please provide doctor/clinic details

Telephone number

i) Have you been with your doctor/clinic for less than 6 months?

If ‘Yes’, please provide previous doctor/clinic details.

Yes No

1. We will be issuing the Confirmation Schedule for both lives to the address

of the First Life. Is this acceptable? Yes

If ‘No’ is selected then we will issue a separate Confirmation Schedule to each life individually. Go to section H. No Clinic address Postcode Name of doctor Telephone number Clinic address Postcode Name of doctor Yes No Telephone number Clinic address Postcode Name of doctor Telephone number Clinic address Postcode Name of doctor

G.Confirmationscheduledetails–foronlinejointapplicationsubmissions

only,otherwisegotosectionH

F. D oc to r/ cl in ic 24 G . C on fi rm at io n sc he d ul e d et ai ls

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Onlycompleteifyouhaveanswered‘Yes’toquestionE4(i)onpage19.

Height m

DISCLOSURE1:

1. Name of activity(s) – include names of ALL aspects of the activity you take part in.

2. Please list any qualification.

3. Where do you take part in this activity – i.e venue type, area of the world etc?

Depth m Height m Depth m

Qualification(s): Years held: Qualification(s): Years held: Qualification(s): Years held: Qualification(s): Years held:

4. How many times a year do you take part? 4. How many times a year do you take part? 5. Do you ever take part alone? 5. Do you ever take part alone?

6. If applicable, what heights/depths do you go to?

Height m Depth m Height m Depth m

6. If applicable, what heights/depths do you go to? DISCLOSURE2:

1. Name of activity(s) – include names of ALL aspects of the activity you take part in.

3. Where do you take part in this activity – i.e venue type, area of the world etc?

Yes No Yes No

4. How many times a year do you take part? 4. How many times a year do you take part? 5. Do you ever take part alone? Yes No 5. Do you ever take part alone? Yes No

2. Please list any qualification.

or ts a nd p as tim es su p p le m en ta ry q ue st io nn air e

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Yes No Yes No

1. What is the medical condition? 1. What is the medical condition?

(i) If ‘Yes’, please give details of how many episodes or attacks of symptoms you have had since onset of condition and describe the nature and severity of the symptoms.

(i) If ‘Yes’, please give details of the problems experienced. 2. Has the diagnosis been confirmed?

D D M M Y Y Y Y D D M M Y Y Y Y

(ii) When did you last have symptoms?

4. Do you have recurrent symptoms?

5.Do they restrict you in any way?

6. Have you seen a specialist for the condition? 6. Have you seen a specialist for the condition?

(i) If ‘Yes’, please give their name and address, the last date you attended and whether you are still attending them or not.

7. What medical investigations have been performed?

8. What were the results (if known) and the dates they were done?

(Pleasenotethatnotallquestionswillberelevantforeachmedicaldisclosuremade) First(oronly)LifeAssured SecondLifeAssured(ifapplicable)

(i). When did symptoms of this condition first occur?

Yes No Yes No

Yes No 5. Do they restrict you in any way? Yes No

Yes No Yes No

3. Are you having any investigations into the cause of your symptoms? Which‘Yes’answerareyoucompletingthisquestionnairefor? I. M ed ic al q ue st 26

First (or only) Life Assured Second Life Assured (if applicable) Failuretodisclose relevantinformation mayresultinnon-paymentofaclaim. Pleasedonot assumethatwe willcontactor obtainareport fromyourdoctor.

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D D M M Y Y Y Y

8. Have all investigations now been completed?

10. How many times have you been admitted to hospital for this condition and when was the last time? (i) No.of admissions

(ii) Date

(i) When did you last see your GP with this condition? (i) When did you last see your GP with this condition?

D D M M Y Y Y Y

(i) No.of admissions

(ii) Date D D M M Y Y Y Y

12. What treatment has been prescribed? (This should include details of all oral steroid prescriptions, e.g. prednisolone.) Please continue on a separate sheet if necessary.

Name of treatment

11. When was the last time you went to hospital as an outpatient for investigations or check-ups for this condition?

Dose (if known)

Name of treatment Dose (if known)

(i) Is the treatment continuing? (i) Is the treatment continuing? (ii) If ‘No’, when did it stop?

(i) If ‘Yes’, please give date(s) of time off work and for how long you were absent from work.

(ii) When was this?

14. Is any operation planned or being considered? 14. Is any operation planned or being considered?

(ii) If ‘Yes’, when is it planned?

(i) What type of operation? (i) What type of operation?

Onlycompleteifyouhaveanswered‘Yes’toanypartsofquestions 7–12 insectionE,onpages20-22.

Yes Yes

Yes No Yes No

(i) Date D D M M Y Y Y Y (i) Date D D M M Y Y Y Y

D D M M Y Y Y Y

Yes

Yes No 13. Have you required time off work?

Yes No

9. Are you waiting for any follow-ups or reviews? 9. Are you waiting for any follow-ups or reviews?

(ii) If ‘Yes’, when is it planned? (ii) If ‘No’, when did it stop?

No No

No

13. Have you required time off work?

(ii) When was this?

ic al q ue st io nn air e Yes No Failuretodisclose relevantinformation mayresultinnon-paymentofaclaim. Pleasedonot assumethatwe willcontactor obtainareport fromyourdoctor.

(28)

(PleasenotethatnotallquestionswillberelevantforeachMedicalDisclosuremade)

Yes No Yes No

1. What is the medical condition? 1. What is the medical condition?

(iv) If ‘Yes’, please give details of how many episodes or attacks of symptoms you have had since onset of condition and describe the nature and severity of the symptoms.

(i) If ‘Yes’, please give details of the problems experienced. 2. Has the diagnosis been confirmed?

(iii) Do you have recurrent symptoms?

4. Do they restrict you in any way?

5. Have you seen a specialist for the condition? 5. Have you seen a specialist for the condition?

(i) If ‘Yes’, please give their name and address, the last date you attended and whether you are still attending them or not.

6. What medical investigations have been performed?

7. What were the results (if known) and the dates they were done? (i) When did symptoms of this condition first occur?

(iii) Do you have recurrent symptoms?

(i) When did symptoms of this condition first occur?

Yes No Yes No

Yes No 4. Do they restrict you in any way? Yes No

Yes No Yes No

3. Are you having any investigations into the cause of your symptoms? WhichYesanswerareyoucompletingthisquestionnairefor? First(oronly)LifeAssured SecondLifeAssured(ifapplicable) I. M ed ic al q ue st 28

First (or only) Life Assured Second Life Assured (if applicable) Failuretodisclose relevantinformation mayresultinnon-paymentofaclaim. Pleasedonot assumethatwe willcontactor obtainareport fromyourdoctor.

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Ifthereareanymoredisclosurespleasecontinueonaseparatesheet.

Onlycompleteifyouhaveanswered‘Yes’toanypartsofquestions 7–12 insectionE,onpages20-22.

D D M M Y Y Y Y

10. How many times have you been admitted to hospital for this condition and when was the last time? (i) No.of admissions

(ii) Date

(i) When did you last see your GP with this condition? (i) When did you last see your GP with this condition?

D D M M Y Y Y Y

(i) No.of admissions

(ii) Date D D M M Y Y Y Y

12. What treatment has been prescribed? (This should include details of all oral steroid prescriptions, e.g. prednisolone.) Please continue on a separate sheet if necessary.

Name of treatment

11. When was the last time you went to hospital as an outpatient for investigations or check-ups for this condition?

Dose (if known)

Name of treatment Dose (if known)

(i) Is the treatment continuing? (i) Is the treatment continuing? (ii) If ‘No’, when did it stop?

(i) If ‘Yes’, please give date(s) of time off work and for how long you were absent from work.

(ii) When was this?

14. Is any operation planned or being considered? 14. Is any operation planned or being considered?

(ii) If Yes, when is it planned?

(i) What type of operation? (i) What type of operation?

Yes Yes

Yes No Yes No

(i) Date D D M M Y Y Y Y (i) Date D D M M Y Y Y Y

D D M M Y Y Y Y

Yes

Yes No 13. Have you required time off work? Yes No

Yes No

9. Are you waiting for any follow-ups or reviews? 9. Are you waiting for any follow-ups or reviews?

(ii) If Yes, when is it planned? (ii) If ‘No’, when did it stop?

No No

No

13. Have you required time off work?

(ii) When was this?

ic al q ue st io nn air e Failuretodisclose relevantinformation mayresultinnon-paymentofaclaim. Pleasedonot assumethatwe willcontactor obtainareport fromyourdoctor.

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J. P la n ss ta K . A cc es s to M ed ic al R ep or ts A ct

K.AccesstoMedicalReportsAct

We may need to get medical reports to support your application. Before we can ask any doctor that you have consulted to fill in a report, we need your permission under the Access to Medical Reports Act 1988. Your rights under the act are as follows. You do not need to give your permission, but if you do not, we may not be able to go ahead with your application. This does not prevent you from applying to other companies for insurance.

You can ask to see the report before the doctor returns it to us. If this is the case, we will tell the doctor to keep 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.

If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date.

If you think that any part of the report is not correct or is misleading, you may ask the doctor to amend it. If your doctor refuses to make the amendments, you may ask him or her to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others.

The medical report your doctor fills in asks about the following:

• Your current health.

• Any care, medication or treatment you are currently receiving. • The results of referrals or tests you are waiting for.

• Any time off work in the last three years. • Your past health.

• Details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultations with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of:

– malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually worsening) diseases;

– musculo-skeletal disease or injury, for example, arthritis, rheumatism, back problems or any other disorder of the joints or muscles;

– anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose contact with reality), stress or fatigue;

– suicidal thoughts or attempts at suicide; or

– conditions related to drug or alcohol misuse or smoking or chewing tobacco.

• Details of any biopsies, blood tests, electrocardiograms (heart tests), height, weight if measured in the last two years,

urinalyses (tests on urine), x-rays or other investigations. • Any blood pressure readings in the last three years. • Any history of disease among your parents or brothers

or sisters that you have told your doctor about.

We have asked your doctor not to reveal information about:

• Negative tests for HIV, hepatitis B or C;

• Any sexually-transmitted diseases unless there could be long-term effects on your health; or

• Predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from.

The information you and your doctor provide about your health may result in us:

• Refusing to provide insurance;

• Increasing premiums above standard rates; or • Setting premiums at standard rates.

If you have any questions about your rights under the act or questions relating to the process of getting, assessing or storing medical information, please write to:

Chief Medical Officer, PruProtect, Stirling FK9 4UE

Important notes

The Plan will not start until we have assessed and accepted your application, and we have been advised of the start date. If you have a birthday while your application is being processed, the terms may differ from those originally quoted. In most instances your payments will be as originally quoted. We may offer you revised terms, but occasionally we may not be able to offer any terms.

We may ask you to contact your doctor if we are waiting for reports which we have asked for.

If we ask you to come for a medical examination, we will need to share the application information with another company we have authorised. They will make the arrangements for the examination to take place.

We may need to send your application and relevant medical reports to our reassurers for their opinion or agreement of the terms offered. Or, we may need to send them at a later stage for purposes relating to managing the policy. You can get details of general reassurance principles and details of any company we use to assess your application, from our head office.

We have a confidentiality policy in place which means we hold your medical information securely and access is limited to authorised individuals who need to see it.

Pleasereadandsignthisdeclarationrelatingtoyourmedicalrecords.

Start immediately on standard term acceptance OR

Choose your plan start date D D M M Y Y Y Y

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How we use your personal data

You are entitled to ask for a copy of our standard terms and conditions and a copy of your application form at any time. It is our policy to obtain a random sample of medical reports shortly after acceptance of insurance contracts to monitor the accuracy and completeness of the information given. By signing this declaration you will be giving us the right to request a medical report. We will write to tell you if we require such a report. Your rights under the Access to Medical Reports Act remain the same. In the event that the medical report highlights a material fact that you have knowingly failed to disclose, we reserve the right to reconsider the terms offered to you or cancel the policy. Please refer to page 35 for the Data Protection Notice. If you have any questions about this please write to: Data Protection Co-ordinator

PruHealth / PruProtect, Marshall Point, 4 Richmond Gardens, Bournemouth, BH1 1JD

For certain products we will need to process sensitive personal information such as health information. By signing and returning this form, you consent to us processing your sensitive information.

The Prudential Assurance Company Limited is part of the Prudential group of companies which at the time of printing includes Prudential UK & Europe, the M&G Investments Group, Prudential Corporation Asia, Jackson National Life, and PPM America Inc (indirect wholly owned subsidiary).

• I/ We agree to you asking any doctor I /we have consulted about my/our physical or mental health to provide medical information so you may assess my/our proposal. You may gather relevant information from other insurers about any other applications for life, critical illness, sickness, disability, accident or private medical insurance that I/we have applied for. I/We authorise those asked to provide medical information when they see a copy of this consent form. This form allows you to gather medical reports within six months of the start of the Plan, or after my/our death, to support any claim made on the Plan proceeds.

• This information can also be used to maintain management information for business analysis.

I/We have read the declaration, important notes and information relating to my rights under the Access to Medical Reports Act 1988.

Declaration

TobecompletedbytheFinancialAdviser.

If you are applying online, please record the application reference number in the box below, as shown on the Intermediary Zone pruprotect.co.uk. Please fax this completed form to PruProtect at 0870 240 0937 or post to PruProtect, New Business, Stirling, FK9 4UE.

Application reference number:

es s t o M ed ic al R ep or ts A ct

Signature of Second Life Assured (if applicable). Full name

✗

Signature Date

Date of birth D D M M Y Y Y Y

D D M M Y Y Y Y

I do not want to see the report before it is sent to the company. I do want to see the report before it is sent to the company. Signature of First or Only Life Assured

Full name

✗

Signature Date

Date of birth D D M M Y Y Y Y

D D M M Y Y Y Y

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ct D eb itd et ail s

First (or only) Life Assured name

Date of birth

(To be completed by the Financial Adviser)

(To be completed by the Financial Adviser) On what date of the month do you want us to collect your premiums?

This must be between 1st_{and 28}th_{of the month} of the month

Papersubmission(PruProtectPlanonly)

For a full application, please ensure your client completes and signs the Direct Debit instruction below. Datacaptureform-onlinesubmissionortele-underwriting

Please collect the Direct Debit details below so that you can submit the details online. Alternatively, your clients can complete and sign the Direct Debit instruction below and you can send this to us at:

PruProtect New Business Stirling FK9 4UE D D M M Y Y Y Y 5 9 9 6 7 5 NameandfullpostaladdressofyourBankorBuildingSociety InstructiontoyourBankor BuildingSocietytopayDirectDebits

To: The Manager Bank or Building Society

Banks and Building Societies may not accept Direct Debit Instructions for some types of account InstructiontoyourBankorBuildingSociety

Please pay PruProtect 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 PruProtect and, if so, details will be passed electronically to my Bank/Building Society. Serviceusernumber

PruProtect is a trading name of Prudential Health Services Limited. Registered offices at Laurence Pountney Hill, London, EC4R 0HH. Please fill in the form and send to: FREEPOSTPRUPROTECT,Stirling,FK94UE.

The Direct Debit Guarantee

Address Postcode Name(s)ofAccountHolder(s) BranchSortCode Bank/BuildingSocietyaccountnumber ReferenceNumber Signature(s) Date

This guarantee should be detached and retained by the Payer.

• 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 PruProtect will notify you at least 5

working days in advance of your account being debited or as otherwise agreed. If you request PruProtect 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 PruProtect 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;

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M.Fullpaperapplicationclientdeclaration,authorityandconsent

–continued _p ap er a p p lic at io n c lie nt d ec or at io n, a ut ho rit y a nd c on se nt Declaration

I/We the Applicant(s) declare that, to the best of my/our knowledge and belief, the information on this form is true and complete and agree that the terms of this Application and Declaration and any statements made by the life or lives to be assured to PruProtect’s Medical Examiner together with PruProtect’s Letter of Acceptance will be deemed to form part of any resultant contracts.

I/We will inform you immediately of any changes that occur before the application is accepted. I/We understand that failure to do so may result in the contract being declared void, and that a claim for the proceeds may not be paid.

*I/We authorise my/our Financial Adviser to act on my/our behalf to amend the sum(s) to be assured or term of the assurance applied for to correspond with any alteration in detail of the mortgage from that set out in this Application and to agree the commencement date of the Plan with PruProtect.

I/We consent to PruProtect seeking details of the mortgage from the lender.

I/We am/are aware that the income benefits I/we receive could affect the amount of any income support/income based Jobseekers Allowance, should I/We be eligible for state help.

Generalinformation

1. By returning this form to us you consent to our processing sensitive personal data about you where this is necessary. 2. Copies of the Plan Provisions and the completed Application

Form are available on request.

3. If anyone else fills in this Application on your behalf, He/She does so as your agent and not as an agent of PruProtect. He/She does not have the authority to accept this Application on behalf of PruProtect.

4. Completion of the Direct Debit instruction does NOT imply commencement of your Plan Assurance risk. PruProtect’s Letter of Acceptance will indicate when the Plan will commence. In most instances your payments will be as originally quoted. Revised terms may be offered to you, for example if you have a birthday while your application is being processed but occasionally we may be unable to offer any terms.

5. The Direct Debit instruction attached is designed to enable you to pay premiums to PruProtect with the minimum of inconvenience as and when they fall due. If the amount payable under your Instruction is due to be altered, PruProtect will advise you of details of the new amount shortly before your account is due for debiting.

Direct Debits under this Instruction will be originated only in respect of premiums payable in accordance with the terms of the Plan for which it is drawn.

6. If the Applicant is not the Life or Lives to be assured, you must have sufficient insurable interest to be able to apply for the Plan on this basis. If in doubt, please check with your financial adviser that sufficient insurable interest exists.

DataProtectionNotice Why you should read this notice

We think it’s important for all our customers to be made aware of what information PruProtect as part of the PruHealth Group* holds about them and to reassure our customers that we comply with the Data Protection Act 1998.

How we use your personal information

PruProtect will use your personal information (including information provided about your dependants) to underwrite, administer, profile your purchase preference and service your Plan. By taking out a Plan with us, you consent to us using your personal information and sensitive personal information (e.g. health information). We will also use your information for statistical data analysis, management information and fraud prevention purposes.

Who we may give personal information to

We may disclose your personal information to other companies in the PruHealth Group, our business associates, agents or service providers for the purposes above. Your information may be used by service providers in a country outside the European Economic Area, which may not have the same standard of data protection as in the UK. We will ensure appropriate safeguards are in place to protect your information.

We will pass your personal information and information about your Plan to any legal or regulatory body if required to do so. We may also use your information or give it to others, for research, statistical purposes or to improve our services, but we will remove your name and address from this first. We may send copies of correspondence relating to your Plan to your Financial Adviser, if you’ve appointed one. We may provide information about a claim to them, although no medical information will be provided without your consent.

When giving us information about another person, you confirm that they have appointed you to act on their behalf. This includes providing consent to process the personal information, receive this Data Protection Notice on their behalf and unless you decide otherwise, receive marketing information.

Your information, and that of others also covered by the Plan, may be given to other parties (for example, other insurance companies) with a view to preventing fraudulent or improper claims.

Please complete this section with your client(s) if you are using this document as a full paper application form.

*TickthisboxifyoudoNOTwishyourFinancialAdviser toactonyourbehalftomakechangesorstartthePlan

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36 M . Fu ll p ap er a p p lic at io n cl ie nt d ec or at io n, a ut ho ri ty a nd _{DataProtectionNotice-continued} I/WehavereadtheinformationrelatingtoMy/OurrightsundertheDataProtectionAct,thedeclaration,important notesandgeneralinformation.

Signature of First or Only Life Assured

Date

✗

Signature of Second Life Assured

Date

✗

Signature of Applicant if different

Date

✗

D D M M Y Y Y Y

Our marketing policy

PruProtect, PruHealth’s group of companies and our business associates, service providers and agents may use your personal information to inform you of other services and products that may be of interest to you by telephone, post, email or text. Please call our Customer Services Team if you would prefer not to receive details of other products.

Obtaining a copy of the information we hold about you

You have the right to request a copy of the information we hold about you or someone you act on behalf of (for which we may charge a fee) and to have any inaccurate information corrected by writing to the Data Protection Co-ordinator at the below address

PruHealth / PruProtect, Marshall Point, 4 Richmond Gardens, Bournemouth, BH1 1JD

Disposal of information

We will continue to hold information about you and your Plan for a reasonable period of time after it has ended. We will then dispose of your personal information in a responsible way to maintain your confidentiality.

Changing this Data Protection Notice

This Data Protection Notice may change from time to time and you should review the contents regularly. We will notify you of any changes where we are required to do so by law. * PruHealth is a joint venture between Prudential in the UK and Discovery Holdings Limited in South Africa. The PruHealth Group includes Prudential Health Limited and Prudential Health Insurance Limited, both trading as PruHealth, and Prudential Health Services Limited trading as PruHealth and/or PruProtect.

Personal Protection. Application/Data Capture form. How Advisers can use this form. Application reference number