MetLife Single Life Relevant Life Policy Proposal Form

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Page 1 of 10 MetLife Single Life Relevant Life Policy

Proposal Form 0800 917 1112 www.metlife.co.uk Invicta House, Trafalgar Place, Brighton BN1 4FR

MetLife Single Life Relevant Life Policy

Proposal Form

The MetLife Single Life Relevant Life policy is provided and underwritten by MetLife Europe Limited, which trades as MetLife. The proposal form must be completed by the policyholder. Please write clearly, sign, date and return the proposal form to your financial intermediary. The proposal form must be returned to MetLife by the financial intermediary within 30 days of MetLife assuming risk. If you have any questions or require help in completing the proposal form please contact your financial intermediary.

Please read this warning carefully.

The insurance policy will be set up based on the information you give us. You must disclose all facts that are material to the insurance and provide true, accurate and complete information. Material facts are facts which would influence us in our decision on the terms and conditions (if any) of the insurance we offer you and are not restricted to the answers to the questions below. If you are uncertain as to whether a fact is material, you should disclose the full details to us. Before the policy commences, you must immediately report to us any change from the answers in this form or to any other information you have provided.

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Proposal Form

1 Applicant’s details

Please complete in block capitals Employer details

Organisation name(s)

Registered address

City Country Postcode

Trading address

City Country Postcode

Scheme name (leave blank if same as employer)

Company registration number (if applicable)

Type of organisation (e.g. limited company, partnership, charity etc.)

Full name and date of birth of the individual, employee or partner to be insured

Nature of trade or business carried out by the individual (please describe the activities of the individual)

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Proposal Form

2 Policy details

This section must be completed even if there is no existing policy.

Please tick one of the following statements as appropriate:

The policy benefit is currently insured with 1 or more insurers or self-insured on an identical benefit basis (Please complete all questions).

The policy benefit is currently insured with 1 or more insurers or self-insured on a non-identical benefit basis (Please complete all questions).

The benefits under this policy are not currently provided to the employee or partner

(Please complete all questions c. and d.).

a. Current insurer

b. Has the employee’s or partner’s benefits been rated, declined, limited to a free salary level or free cover limit under a previous employer-sponsored single life relevant life policy?

Yes No (If “Yes” please complete table below)

Benefit £ Underwriting decision Reason for decision Date of decision

Subject to any temporary cover provided during the underwriting process, please note that the employee or partner will not be granted cover under the policy until satisfactory evidence of health is received and the risk is accepted by MetLife.

c. Is there a current or pending income protection / permanent health insurance claim in respect of the employee or partner? Has the employee or partner been absent from work for more than 90 continuous days at the commencement date?

Dates of absence from / to Cause Lump sum benefit £

d. Is the employee or partner based overseas or do they travel overseas for business purposes?

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Proposal Form

3 Basis of Benefits

Please select the benefit basis required. A maximum Life benefit of up to 10 x salary or earnings can be selected.

X Salary or

Lump sum (e.g. £100,000)

£ Definition of salary or earnings

(if multiple of salary chosen)

Examples:

1. Basic annual salary at review date coinciding with or preceding the date of claim 2. Basic annual salary at the date of claim

3. P60 earnings

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Proposal Form

4 Eligibility

Termination Age Were any of the following coverages quoted?

Redundancy cover

Redundancy cover period (in months) Early retirement cover

Late retirement cover

Late retiree termination age Are the above currently insured? (If “Yes” please provide details)

Yes No

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Proposal Form

5 Actively at Work Declaration

This applies to both currently insured and new policies and refers to this Single Life Relevant Life proposal. Unless specified by MetLife in writing, this Actively at Work declaration must be completed.

On the last working day before the commencement date of the single life relevant life policy, did the employee or partner not meet the Actively at Work definition (as set out below) on the last working day before the commencement date due to accident or sickness?

Yes No If Yes, please provide details:

Cause Dates of absence from/to Benefit £

In the event they are not actively at work on the last working day before the commencement date due to accident or sickness, the employee or partner will not be granted cover until satisfactory evidence is received and they are accepted for cover by MetLife.

Definition:

Actively at work means, in relation to the employee employed by the employer or the partner of the employer at any relevant date, that they have not received medical advice to refrain from and are actively engaged in or are otherwise following their normal occupation on that date. Actively means the employee or partner is, in the opinion of the insurer, mentally and physically capable of working their normal contracted number of hours, either at their usual place of business or at the location to which business requires them to travel.

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Proposal Form

6 Commencement and declaration

We hereby request that MetLife assume cover for the above named Single life Relevant Life Policy in accordance with the standard policy terms and conditions provided with:

Quotation No. Dated

D D M M Y Y Y Y

We understand that the above quotation is subject to the information supplied by us in response to MetLife’s underwriting questions. We understand that if any material facts supplied by us in this Proposal Form affect the premium rate detailed in the quotation above, a new quotation will be issued. We also understand that MetLife will not assume risk, until we have received written confirmation that their underwriting criteria have been satisfied.

Commencement date and payment frequency

Requested commencement date Requested review date

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

(assumed 1 year after the commencement unless stated) MetLife will confirm in writing the date cover has commenced. This date cannot be backdated.

Frequency with which premiums will be paid Annual Bi-annually Quarterly Monthly

Declaration

We declare that we have disclosed all facts material to the insurance cover and that the answers to the questions or to MetLife’s underwriting questions in this form are true, accurate and complete. We agree that the application, together with statements made and information supplied by us in connection with the application, shall form the basis of the policy cover(s) granted by MetLife. We have read the data protection and confidentiality notice below and we note and understand the purposes for which personal data and sensitive personal data will be stored and processed by MetLife and with whom the data may be shared or transferred. We warrant that personal data provided to MetLife for the purposes of the Single Life Relevant Life Policy is provided in accordance with the rights of the data subject under the Data Protection Act 1998.

We consent to MetLife seeking information from any insurance company to which a proposal for single life relevant life cover has been made and we authorise the giving of such information.

We understand that we must notify MetLife of any change in the answers to the above questions and information supplied before the insurance cover commences.

We acknowledge and understand that it is not MetLife’s responsibility to advise on and confirm the way in which any policy operates, in particular regards to the tax treatment of a policy and whether it meets the relevant criteria of HM Revenue and Customs.

We agree to furnish such medical evidence and confirmation of age satisfactory to MetLife as may be requested from time to time.

Please ensure one of the authorised signatories as identified overleaf signs this declaration.

We confirm that an electronic copy of this proposal form shall have the same validity as the original.

Signature Position

Name Date

D D M M Y Y Y Y

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Proposal Form

7 Authorised signatories

For completion of claims and policy documentation please provide a minimum of 2 authorised persons.

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Proposal Form

Data protection and confidentiality notice

Information relating to an individual (the data subject), or personal data or sensitive personal data (for example their medical notes and records) as defined by the Data Protection Act 1998, whether included in this application or otherwise, is private and confidential. We comply with all legislation relating to Data Protection. We hold or process personal data or sensitive personal data for the purposes set out below.

We will store and process data for underwriting and claims, fraud and crime prevention and detection, marketing purposes, to carry out research and analysis, to set up and administer, and provide information about the policy or the linked policy in connection with any reinsurance and in connection with any subsequent application(s).

We may share with or transfer data relating to an individual for the above purposes to our parent company and other companies within the company group, to our successors or assigns, to other insurers, to insurance intermediaries, to our service providers, to our reinsurers or to third party companies to process or manage information on our behalf. These companies may operate outside the European Economic Area. Data will be processed as securely as if we were processing it, under a strict code of privacy and security.

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Products and services are offered by MetLife Europe Limited which is an affiliate of MetLife, Inc. and operates under the “MetLife” brand.

MetLife Europe Limited is authorised by the Central Bank of Ireland and subject to limited regulation by the Financial Conduct Authority. Details about the extent of our regulation by the Financial Conduct Authority are available from us on request. Registered address: 20 on Hatch, Lower Hatch Street, Dublin 2, Ireland. Registration number 415123. UK branch address: One Canada Square, Canary Wharf, London E14 5AA. Branch registration number BR008866. www.metlife.co.uk