Clerical Medical
Flexible
Savings Plan
Basic life cover
Your Flexible Savings Plan will
already include a basic level of life
cover, which means that, if the
relevant life assured dies the
amount paid will be:
●
the bid value of the units
allocated to your Plan, plus (in
the case of units in Guaranteed
Growth Funds) any claim bonus
dividend
●
plus, an extra 1% where selected.
The protection benefits set out in
this guide can give you additional
security. Selected protection
benefits and basic life cover on your
Plan, will be subject to a maximum
number of lives assured. This is two
for joint life first death plans (the
first to die of two lives), and six for
joint life last death plans (the last to
die of up to six lives).
You choose the life basis of the
Flexible Savings Plan on the main
application form. Where there are
more than two lives assured,
charges and underwriting for the
selected protection benefits will
apply to the two youngest lives
assured.
The optional protection benefits
available are:
1. Life cover, available in a range of
options:
●
standard cover over the term
of your plan,
●
term cover to give you extra
security over a selected
period of time
●
a combination of standard
cover and term cover.
2. Waiver of premium, to protect
the ongoing regular premiums to
the plan should the relevant
assured life suffer from an illness
or an accident.
Selected protection benefits
You can choose protection benefits
at the start of your Flexible Savings
Plan.
You can also add the life cover
options during the term of your
Plan, subject to satisfactory
evidence of health, or other
evidence as CMI Insurance
Company Limited may require. You
can only choose waiver of premium
at the start of your Flexible Savings
Plan.
Life cover
i. Standard cover
You can select a standard cover sum
assured to be paid on the death of
the relevant life assured for your
plan. This can be either on the
death of a single life, joint life first
death or joint life last death, and
must be selected in your Flexible
Savings Plan application form.
By selecting standard cover, you can
choose the sum assured that you
wish to be paid on the death of the
relevant life assured, instead of the
basic life cover. Standard cover
applies for the whole plan term.
Where standard cover is in place the
amount paid on the death of the
relevant life assured is either the bid
value of units allocated to your
Plan, or the sum assured, whichever
is higher.
Example
If you select standard cover and
you choose a life cover amount of
$400,000, on the death of a
relevant life assured, then if the
fund value is $300,000, the plan
would pay out a total amount of
$400,000.
1
Protection benefits
explained
ii. Term cover
The alternative cover will enable you
to choose a level of life cover that
you wish to be paid on the death of
the relevant life assured.
Term cover is, however, paid in
addition to the basic cover available
through your plan, or in addition to
standard cover if also selected.
Example
If you select term cover and you
choose a life cover amount of
$400,000, on the death of a life
assured if the fund value is
$300,000, the plan would pay out
a total amount of $700,000.
You can select how long the term
cover continues for (ie it does not
have to continue for the whole plan
term as standard cover does).
You can select standard cover and
term cover to apply to your Flexible
Savings Plan at the same time.
Example
If you select standard cover and
term cover together, and you
choose $400,000 standard cover
and $500,000 term cover (for the
first ten years of the Plan), and if
the relevant life assured dies
during the first ten years of the
Plan – they would receive the
greater of the standard cover
and the Plan value, under the
standard cover option, as well as
$500,000 from the term cover.
After ten years the term cover will
cease and the amount of cover
would be the greater of the
standard cover and the Plan
value.
Waiver of premium
This benefit can only be selected at
the start of your Plan. Regular
premiums will be paid by CMI
Insurance Company Limited. If the
relevant life assured suffers an
illness or accident and becomes
unable to work.
The definition of ‘unable to work’
varies according to the country in
which the life assured resides.
Please ask your financial adviser for
details of which definition applies in
your jurisdiction.
The definition used will be one of
the following:
a. ‘the life assured is temporarily
unable by reason of sickness or
accident to follow his own
occupation, is not following any
other occupation(s) and is
unable to follow any other
occupation for which he is
fitted by reason of education,
training’, or
b. ‘the life assured is temporarily
totally unable by reason of
sickness or accident to follow his
own occupation and any other
occupation(s),’ or
c. ‘the life assured is permanently
totally unable by reason of
sickness or accident to follow his
own occupation and any other
occupation(s).’
If definition a. applies to the lives
assureds’ country of residence, and
they are not in employment, waiver
of premium will not be available.
Where definition a. applies, the plan
owner must inform CMI Insurance
Company Limited of any change in
occupation of the relevant life
assured (including unemployment
and retirement). This may result in
one of the other definitions being
applied or, the benefit being
cancelled.
The regular premiums will be paid
by CMI Insurance Company Limited
after 26 weeks of disability and
will continue to be paid by CMI
Insurance Company Limited until
the earlier of:
a. recovery of the life assured
b. the life assured reaching the age
of 65
c. the end of any limited premium
payment term you have selected
d. the death of the relevant life
assured.
Any future increases due under the
automatic premium increase option
will also be paid by CMI Insurance
Company Limited.
While your premiums are being
paid, all protection benefits in your
Plan will be maintained, providing
there are sufficient funds to support
the charges and, if you have
selected the automatic benefit
increase option, (see section on
page 3) your protection benefits will
continue to increase.
3
Charges for selected
protection benefits
We make a monthly charge to cover
the cost of providing your selected
protection benefits. It is taken by
cancelling the appropriate number
of accumulation units. During the
initial period, when no accumulation
units are held, the cost of selected
protection benefits will accumulate
as a debt, and will be paid off
using the first accumulation units
purchased after the initial period
ends.
The charge for the cost of providing
your selected protection benefits is
based on factors relating to the life
or lives assured including:
●
Age
●
Health
●
Sex
●
Smoker status
●
Country of residence.
These charges may vary from time
to time, in line with the expected
costs of providing these benefits.
If your plan is paid-up, any selected
protection benefits will continue for
as long as there are sufficient
accumulation units to pay the cost
of providing the cover.
Where there are insufficient
accumulation units available to pay
the cost of the selected protection
benefits, the cover provided by the
protection benefits will cease.
If you wish to reinstate regular
premiums, to a paid-up or lapsed
Flexible Savings Plan, the
reinstatement or continuation of
any selected protection benefits will
be subject to further underwriting.
Automatic benefit increase
option
You can choose for your selected
protection benefits to increase each
year, without the need to provide
any further of evidence of health.
At the start of the Plan, you can
select this option when you have
chosen for your premiums to
automatically increase.
If chosen, your initial maximum
sum assured for life cover and
waiver of premium will be reduced.
Standard benefit increase
option
Any one or more of your selected
protection benefits can be increased
on any date when a premium is due.
An appropriate increase in the
selected protection benefit
premiums will be necessary.
The standard benefit increase
option is not available with joint life
last death plans.
Increase under this option will be
subject to:
i. Satisfactory evidence of health
or other evidence as CMI
Insurance Company Limited may
require
ii. Acceptance of the increase by
CMI Insurance Company Limited
on the same underwriting terms
as existing benefits
iii. The total benefits following the
increase must not exceed those
set out opposite.
iv. The increase must be on the
same life/lives assured and on
the same basis (eg joint life first
death) as existing benefits
v. The minimum levels for single
or increases to regular premiums
are set out in the Flexible
Savings Plan technical guide
(reference HE103)
vi. If waiver of premium applies to
the Plan, any increase in regular
premiums to the Flexible Savings
Plan must have waiver of
premium cover, and will be
subject to further underwriting.
Reducing protection
benefits
One or more of your selected
protection benefits may be reduced
on any date when a premium is due.
Minimum and maximum
ages of lives assured
The minimum and maximum ages
for the relevant lives assured, at the
start of the Plan vary with the types
of protection benefit.
Ages outside the above ranges will
be considered by CMI Insurance
Company Limited and will be
allowed at its discretion.
Benefit Minimum Maximum
age age
Basic life cover 18 years 69 years Standard cover 18 years 64 years Extra cover 18 years 64 years Waiver of premium 18 years 59 years Automatic benefit
increase option 18 years 54 years
Minimum sums assured
Plan currency Type of benefit US$ E £ sterling HK$ Standard cover 1,000 1,000 1,000 10,000 Term cover 1,000 1,000 1,000 10,000 Plan currency Type of benefit US$ E £ sterling HK$Standard cover/term cover 2,500,000 2,000,000 1,660,600 20,000,000 Waiver of premium
(annual amount of cover) 50,000 40,000 33,300 400,000
Maximum sums assured from outset of the Plan
Notes
●
The maximum sums assured are the overall maxima. Further restrictions
may apply depending on the combinations of protection benefits you
select for your Plan and the country of residence of the life/lives
assured.
●
Higher amounts of benefit may be permitted at the discretion of
CMI Insurance Company Limited.
Issued by CMI Insurance Company Limited, Clerical Medical House, Victoria Road, Douglas, Isle of Man IM99 1LT, British Isles. Registered No. 33520 Isle of Man. Telephone: +44 (0)1624 638888. Fax: +44 (0)1624 625900.
Hong Kong Representative: CMI Financial Management Services Limited, Unit 2408, 9 Queen’s Road Central, Hong Kong. Telephone: +852 2956 1288. Fax: +852 2956 2302.
The above companies are part of the HBOS Group
www.clerical-medical.com E964/1106 (HE104/1106)
Clerical Medical
Flexible
Savings Plan
Protection benefits
application form
Please ensure that the application is accompanied by the required
certified information.
Failure to provide ALL relevant documentation will cause delay in the
processing of this application.
A. How to complete this form
●
If you are applying for a Flexible Savings Plan at the same time as
applying for protection benefits, please attach this completed
supplementary application form to the main application form
(reference HE101).
●
Please answer all questions in English, in CAPITAL LETTERS using a
blue or black pen.
2
Applicant one
Please enter amounts in your Plan currency i. Standard cover
ii. Term cover (minimum of five years)
iii. Waiver of premium
Automatic benefit increase option
Mr/Mrs/Miss/Ms or other title First name(s) (in full)
Family name
Policy number (if known)
Permanent address (in full)
Date of birth (DD/MM/YYYY) Contact telephone number
Amount for the term of your plan
Amount term (whole years only)
Life one Life two
By ticking this box your selected benefits will increase in line with the automatic premium increase option selected on your Flexible Savings Plan. This is only available if automatic premium increase option has been chosen.
Where this option has been selected, the maximum amounts of protection benefits at the start of the Plan will be reduced.
/
/
Is the applicant a life assured? Yes No
Applicant two
Mr/Mrs/Miss/Ms or other title First name(s) (in full)
Family name
Permanent address (in full)
Date of birth (DD/MM/YYYY) Contact telephone number
/
/
Is the applicant a life assured? Yes No
B. Details of applicants
(to be completed by the applicant(s))
Please add the details of the applicant(s) who is/are applying for a Flexible Savings Plan and wish to have protected benefits added.
This information must be the same as that completed in section B of the main application form (reference HE101) for the Flexible Savings Plan.
C. Medical questionnaire
This section should be completed by the two youngest lives assured named in sections B and D of the main application form (reference HE101).
If you answer ‘Yes’ to any question, please provide additional information in the section at the back of this form, or complete the appropriate form if required.
Life one Life two
Yes No Yes No
Live assured name
1. Is there any feature of your lifestyle, work or leisure activities or any other circumstances or fact, which might affect or threaten your health or life expectancy?
Total cover Currency
Total cover Currency benefits with other companies?
● Do you intend to discontinue any existing cover?
4. Please state total amount of cover (including currency) taken out on your life in the last 12 months, including reinstated policies.
5 Please state your height and weight *please delete as appropriate
6. In the past 12 months have you used tobacco products? If ‘Yes’, what is your daily consumption?
7. Do you intend to:
i. Fly, other than as a fare-paying passenger on scheduled airlines or participate in any hazardous pursuits
(eg underwater diving, parachuting, motor racing)? If ‘Yes’, please complete the supplementary aviation or pursuit questionnaire which can be obtained from your financial adviser.
ii. Will you be out of your stated country of residence for 30 days or more in any one year?
8. Do you expect to seek a medical opinion within the next eight weeks?
9. Current doctor
Please provide details of your usual doctor. If you have no usual doctor, please supply details of the last doctor you consulted, including the reason.
10. Have you ever been advised to give up smoking for any specific reason?
11. Please give your average weekly consumption of alcohol (quantity and type). Please complete all boxes.
Height Weight (lbs/kg*) Height Weight (lbs/kg*) Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Name of doctor Address of doctor No of years attended Country Telephone number
Reason for visit
Name of doctor
Address of doctor
No of years attended Country
Telephone number
Reason for visit
4
Life one Life two
Do you have or have you ever had any of the following?
13. Heart or circulatory disorders (eg high blood pressure, stroke, chest pain, heart murmur, palpitations, rheumatic fever, blood vessel disorders, elevated cholesterol level)?
14. Respiratory or lung trouble (eg asthma, bronchitis, persistent cough, tuberculosis)?
15. Disorder of the digestive system, gall bladder or liver (eg duodenal ulcer, bleeding from the bowel, hepatitis)? 16. Disease or disorder or infection of the kidneys, bladder or
reproductive organs (eg protein or blood in urine, stones, prostatitis, venereal disease)?
17. Nervous, neurological or mental complaint (eg fits, epilepsy, blackouts, persistent headaches, paralysis, anxiety state, depression)?
18. Ear, eye, nose, throat or skin disorders (eg ear discharge, defective vision, recurrent tonsillitis, porphyria, psoriasis, dermatitis)?
19. Disorders or disease of muscles, bones, joints, limbs or spine (eg rheumatism, arthritis, gout, slipped disc, other back or neck troubles)?
20. Diabetes, sugar in urine, blood, spleen or bleeding disorders, thyroid or other glandular disorders?
21. Cancer, leukaemia, tumour or growth of any kind?
22. Are any medicines or drugs currently prescribed to you, or are you receiving any medical or psychiatric treatment or advice or awaiting surgery?
23. Have you received, or do you expect to receive, any advice, counselling, treatment or blood tests in connection with AIDS, HIV or an HIV related disorder or any sexually transmitted disease including hepatitis B?
24. Have you ever been counselled or treated in connection with alcohol or drugs?
25. Does/Has any member of your immediate family suffer/suffered from cancer, diabetes, stroke, multiple
sclerosis, kidney disease, heart disease, high blood pressure or any hereditary disease before the age of 65?
If ‘Yes’, please provide full details, including the family member and age.
Females only (questions 26 and 27)
26 Have you, or have you ever had, any disorder of the female organs (breasts, ovaries, uterus) or any abnormality of pregnancy or confinement (eg caesarean section or miscarriage)?
27. Are you now pregnant? If ‘Yes’, how many months?
If you are unsure whether a particular fact is relevant, you should disclose it. Protection benefits may be forfeited, if relevant information is found to have been withheld. Any policy of insurance issued pursuant to this application may be declared void, even if the application has been formerly accepted by CMI Insurance Company Limited (‘the Company’), where facts which are material to this application have been withheld. In such event, all monies paid may be forfeited. Please give careful consideration to the declaration before signing it. Before the Plan comes into force, any change of facts contained in the answers given in this application must be notified to the Company in writing. The Company reserves the right to amend the terms on which your application may have been accepted or to withdraw acceptance in the event of any such change.
You should remember that any person (except for a member of the Company’s staff) who is advising you regarding the Plan(s) for which you are applying, is acting for you and not on behalf of the Company.
Your application is not binding and no contract will exist until the Company has issued a letter of acceptance or your Policy Certificate and all conditions therein have been complied with. Full details of the Plan can be found in the Principal Brochure. Copies of the completed Flexible Savings Plan application form, this protection benefits application form and the policy conditions will form part of your policy document.
E. Notice and Consent in relation to the Personal Data (Privacy) Ordinance
of Hong Kong
1. In order to enable us to assess your application, you are required to supply all the information requested in this application form (‘personal data’) and your failure to do so may result in our inability to assess your application.
2. The personal data will be used by us for considering your application for the requested policy or investment and related services. The personal data and details of, or information relating to, all or any transactions or dealings involving such policy or investment and services will be used in connection with our provision of such policy or investment and services to you. Without restricting the general scope of the aforesaid, we will use, hold, store, disclose, transfer (whether within or outside Hong Kong) and/or exchange such personal data, details and information to or with all such persons and/or entities as we may consider necessary (including, without limitation, the persons and entities specified below for any and all purposes specified below).
Persons and entities
Any of the persons or entities referred to below may utilise the personal data in the course of any business carried on by such person or entity.
a. Any part of the HBOS Group of companies
b. Any agent, broker and/or sub-contractor appointed or engaged by us or you c. Any insurance or reassurance company
d. Any medical society, hospital or institution providing health or medical advice e. Any bank or other financial institution
f. Any other persons or entities providing banking or financial services or facilities to enable payment by electronic means or via other communication media or similar or related services or products.
Purposes
a. In connection with our assessing and providing the financial product or service requested by you from time to time and related services
b. In connection with matching for whatever purpose (whether or not with a view to taking any adverse action against you) any such personal date with other personal data concerning you in our possession
c. In connection with any verification or exchange of information, or investigation
d. In connection with any system or facility for payment by electronic means or via other communication media in which we participate
6
I/We declare that I/we have read and understand the important notes within this application and that all the statements made by me/us whether in my/our handwriting or not, are true and complete to the best of my/our knowledge and belief and I/we have disclosed all relevant information concerning this application, whether or not covered by the questions in the main Flexible Savings Plan application form, this protection benefits application form and any supplementary questionnaires which might influence the Company’s decision concerning this application, including whether to assume risk and the amount of premium(s).
I/We will disclose to the Company any changes to the information given in this application which occur following the completion of
this application but prior to the receipt by me/us of an acceptance letter/the policy documentation.
I/We irrevocably consent to the Company seeking from any doctor, hospital, medical institution or other person, information which may be related to my/our occupation, physical or mental health, including the results of any tests, and I/we authorise the giving of such information. This authorisation shall remain in force after my/our death.
In relation to the Personal Data (Privacy) Ordinance of Hong Kong, I/we accept the notice in section E and give my/our consent.
1. Not all of the selected protection benefits are available for lives assured resident in certain regions of the world. All selected protection benefits are subject to minimum and maximum levels.
2. Life cover benefit will not be paid as a result of suicide in the first year of cover or the first year of cover following a reinstatement. Other exclusions may apply in certain regions of the world.
3. Waiver of contribution benefits will not be paid if a claim arises directly or indirectly from:
● Unreasonable failure to seek or follow medical advice
● Drug or alcohol abuse
● Wilful self-inflicted injury
● Any Acquired Immuno-Deficiency Syndrome (AIDS) or infection by any Human Immuno-Deficiency Virus (HIV)
● Material violation of law
● Participation in a hazardous sport or pursuit
● Pregnancy
● War.
4. Any claim under your Plan will be subject to a specified period of notification of the event giving rise to the claim, together with specified evidence that the event has occurred and relevant circumstances of the event.
5. If the value of your Plan is likely to be insufficient to sustain the cost of selected protection benefits, it will be necessary for you to pay a further single premium, increase your regular contributions or reduce the level of the selected protection benefits.
CMI Insurance Company Limited guarantees that all selected protection benefits chosen at commencement of your Plan will be maintained for five years, irrespective of investment returns and charges, provided that a. any regular contributions are maintained at the contracted level, and b. throughout this period your Plan is linked exclusively to the Guaranteed Growth Funds and no switches and no encashment (not specified at outset) from the Guaranteed Growth Funds take place. 6. IMPORTANT – The descriptions of selected protection benefits
in this section are intended as a guide only and for full details of the terms, conditions and exclusions applicable to these benefits you should refer to the policy conditions, which are available separately.
Name of first applicant Signature Date / /20
Name of second applicant Signature Date / /20 In which country was this application form signed?
Life assured Signature Date / /20
Life assured Signature Date / /20
Witnessed by financial adviser (signature)
Name of financial adviser (in CAPITAL LETTERS)
Name of financial adviser’s company (in CAPITAL LETTERS)
Financial adviser’s stamp
Financial adviser’s reference number
Date / /20
Financial adviser details
In which country was this application form signed?
Lives assured (if different from the applicant(s))
This should only be signed by the two youngest lives assured, unless applicants. Details of lives assured must be supplied in section D of the main application form.
Signatures of applicants and lives assured (this section MUST be completed)
F. Declaration and applicants/lives assured signatures
Additional information continued
Please quote the question number and the life assured details to whom this information relates.
Issued by CMI Insurance Company Limited, Clerical Medical House, Victoria Road, Douglas, Isle of Man IM99 1LT, British Isles. Registered No. 33520 Isle of Man. Telephone: +44 (0)1624 638888. Fax: +44 (0)1624 625900.
Hong Kong Representative: CMI Financial Management Services Limited, Unit 2408, 9 Queen’s Road Central, Hong Kong. Telephone: +852 2956 1288. Fax: +852 2956 2302.
The above companies are part of the HBOS Group www.clerical-medical.com
E964a/1106 (HE104a/1106)
