Group Income Protection Insurance -
Employee’s Questionnaire
Your employer has asked us to pass on this questionnaire to you. Your answers will help us to understand the current illness or injury that is causing your absence from the workplace.
Unum may contact you directly. This will be for medical and support purposes only and no payment details will be discussed. Please read the accompanying document entitled Your Statutory Rights and sign enclosed Consent Forms. You should then: • Return the signed Consent Form together with this completed questionnaire directly to Unum at Unum Claims, Milton Court,
Dorking, Surrey, RH4 3LZ.
Please complete all boxes as fully as you can using black ink. You should then return this form to Unum. If you are in any doubt as to whether you need to disclose a particular fact to us, please state it in full.
Your Details
1. Scheme Details
Life ID (if known) Employer’s name
2. Personal Details
Name and Title Address
Telephone Home Mobile
Email address
Date of birth (dd/mm/yyyy) / / National Insurance Number
3. What is your height and weight? Height Weight
4. Are you predominantly? Right Handed Left Handed
Postcode
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Your Medical Condition
1. Date of commencement of continuous absence. / /
2. Please describe your illness or injury. Have you been given a diagnosis? If so, what is it and when was it made?
3. Is your condition: Deteriorating Improving Stable
Please provide details, below
4. Are your symptoms: Constant Intermittent
Please provide details, below
5. Have you suffered with this condition before? (If so, please provide details including dates).
6. What do you believe to be the cause of your condition?
7. How often are you seeing your doctor? 8. What advice and treatment are you receiving?
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9. Name and address of your General Practitioner Name and address of your Consultant or Specialist
(please write NONE if no other doctor consulted)
Please attach additional sheets if necessary
10. What medication are you being prescribed? Please list the names and dosages.
Name Dosage Frequency
Your Daily Activities
1. What are your current difficulties in terms of activities of daily living, i.e. can you do the shopping, gardening, cleaning, washing, bathe independently, etc?
2. Please detail your normal daily routine (from waking up to going to bed).
AM PM
Monday
Tuesday
Date of next appointment Date last consulted Tel No.
Postcode
Date of next appointment Date last consulted Tel No.
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Wednesday
Thursday
Friday
Saturday
Sunday
3. Do you participate in any hobbies or social/community activities? (e.g. religious organisations, volunteer work, etc). Please provide detailed information.
4. Are you currently allowed to drive? Yes No
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Your Work
1. What is your current job title?
2. How long have you been doing your current job? 3. Please describe your duties in detail.
4. How does your condition and its symptoms affect your ability to work?
5. Do you receive a regular performance appraisal? Yes No
6. When was your last performance appraisal?
7. Are you in contact with your employer? How often? What have you discussed?
8. Have you attempted to, or are you considering or planning to
return to any form of work either on a part-time or full-time basis? Yes No
Please provide details.
9. Would you be interested in help from our Rehabilitation and Health Management
Services to get you back into work? Yes No
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Additional Information
1. Please provide the following information:
Name Date of Birth
1) Spouse
2) Dependant Children
3) Any other dependants
2. Have you applied for Employment and Support Allowance?
(normally after 28 weeks of absence) Yes No
If No, please state why
3. Do you hold any other Sickness or Accident Insurance Policies? Yes No
If Yes, please give details below
Name and Address of Insurer Type of Policy Policy Number Annual Benefit (£) Duration of Benefit
4. Please provide details of any other claims for this illness or injury (e.g. public liability, motor insurance claim, etc) and/or any other sources of income.
UP333b Honeywell 08/2015
Unum Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Registered Office and mailing address: Milton Court, Dorking, Surrey RH4 3LZ Registered in England 983768 Unum Limited is a member of the Unum Group of Companies.
We monitor telephone conversations and e-mail communications from time to time for the purposes of training and in the interests of continually improving the quality of service we provide.
unum.co.uk
Page 7 of 7
Declaration
1. I have read and understood my statutory rights as set out in the accompanying document entitled “Your Statutory Rights”. 2. I consent to Unum holding personal sensitive data about me for the purposes of assessing this claim.
3. I declare that all statements made are true and complete to the best of my knowledge and belief and that I have disclosed all information material to this claim for benefit.
4. I understand that if any information provided is found to be deliberately misleading, or if I fail to provide material information, this claim may be rejected.
5. I will attend an Independent Medical Examination with a health professional appointed by Unum if requested to do so for the purpose of assessing this claim.
Signed Date (dd/mm/yyyy) / /
