forenadeliv.se/sulf
Accident insurance
Member
Co-insured
Disability compensation (up to) 800 000 SEK
Disability compensation (up to) 1 200 000 SEK
Disability compensation (up to) 1 600 000 SEK
Health insurance, members only. Free coverage for three months - valid if under 36 years of age.
Monthly salary
Monthly compensation (up to)
– SEK 26 999
SEK 1 500
SEK 27 000 – SEK 34 999
SEK 3 000
SEK 35 000 and above
SEK 4 500
Life insurance
Death compensation (up to)
Income compensation (up to)
SEK 267 000
SEK 267 000
SEK 445 000
SEK 445 000
SEK 667 500
SEK 667 500
Child insurance, can only be taken out by members. If you choose an amount
over 30 pbb you must fill in a health declaration for all children aged 1 year or more.
Diagnostic insurance and medical care cost cover are included.
Disability compensation (up to) Premium per month regardless of number of children
SEK 890 000 (20 pbb)
144 kr
SEK 1 335 000 (30 pbb)
181 kr
SEK 1 780 000 kr (40 pbb)
228 kr
SEK 2 225 000 kr (50 pbb)
274 kr
Send your application/declaration of health postage free
to: Frisvar Förenade Liv Gruppförsäkring AB, Svarspost
121310901, 110 00 Stockholm
Continued on next page
Members’ Insurance Application
As a new member, you will receive three months of coverage free of charge. See highlighted text below.
FL1586 15.03 (FL 1155)
You can fill out your insu
rance
application, direct debit f
orm and
declaration of health onlin
e!
SULF
Member since year month Group contract no.9115
Member surname, forename Civic registration no.
Telephone E-mail
Address Postal code and town
Co-insured spouse or partner surname, forename Civic registration no.
forenadeliv.se/sulf
Applicant’s signature
Date Work phone (plus dialling code) Home phone (plus dialling code)
Member’s signature Co-insured’s signature
Are you fully fit to work?
Member
Yes
NoCo-insured
Yes
NoBeing fully fit for work means that you:
• can perform your normal work without restrictions
• do not receive or are not entitled to compensation in relation to your own illness, accident and/or disability or have such
compensation pending.
Special qualifications apply to persons receiving in subsidised employment, persons who have been granted leave due to illness in order
to seek new work, and persons granted health-related occupation modifications. These restrictions can be found in the Terms and
Conditions.
Persons who have been granted care allowance or suspended compensation or similar compensation are not considered fully fit to work
fully fit to work in relation to medical care insurance.
In order to be considered fully fit for work when taking out medical care insurance, the applicant must not have been entitled to
com-pensation for illness and/or accident for more than 14 consecutive days during the last three month period.
Please note
The amounts stated are for 2015
Please note that certain policies may be subject to restrictions and reduced compensation amounts. For more information, including
prices, please see the brochure “Your SULF Members’ Insurance”, in the “Important Information” folder and at forenadeliv.se/sulf
Family cover
Member
Co-insured
Monthly death compensation
SEK 3 783
SEK 7 567
Declaration of Health
FLG-660
If you answer ‘yes’ to any of questions 1-18, you must provide supplementary information on the back of this form.
This declaration of health must be completed in person by the applicant. It is important that you
answer every question. Send your application/declaration of health in a postage-free envelope
to: Frisvar, Förenade Liv Gruppförsäkring AB, Svarspost 121 310 901, 110 00 Stockholm
Group contract number
Name of member (group member)
Civic registration number
Name and surname of co-insured, spouse or partner
Civic registration number
Are you fully fit to work?
Member
Yes
No
Co-insured
Yes
No
In order to be considered fully fit to work, you must be able to perform your normal work without restrictions. ‘Fully fit to work’ excludes persons who are on any level of sick leave, or receiving sick pay, sickness or rehabilitation benefits, extended sickness benefits, activity compensation, temporary sickness compensation, sickness compensation, or occupational injury annuity at a rate of 50% or more. Persons who have been granted care allowance or suspended compensation are not considered fully fit to work. Special qualifications apply to persons receiving subsidised employment, persons who have been granted leave due to illness in order to seek new work, and persons granted health-related occupation modifications. These restrictions can be found in the Terms and Conditions
.
* sought medical care = e.g. taken sick leave, received care, treatment, monitoring or examination at a hospital, medical centre, treatment clinic or other
healthcare institution or contacted a doctor, nurse, physical therapist, chiropractor or naturopathic treatment provider due to conditions/symptoms/illness/
handicaps in one of the following body parts/organs and/or one of the following conditions.
Have you sought medical care as defined above* at any time during the past three
years due to:
Member
Co-insured
1. Allergies, asthma and/or any other respiratory illness?
Yes
No
Yes
No
2. Skin condition/skin disease?
Yes
No
Yes
No
3. Goitre and/or any other metabolic disorder?
Yes
No
Yes
No
4. Eye and/or ear disease, tinnitus?
Yes
No
Yes
No
5. A condition or disease of the back, neck, shoulders, arms, hips, legs, knees, feet
and/or hands?
Yes
No
Yes
No
6. A condition or disease of the muscles and/or joints?
Yes
No
Yes
No
7. Nervous condition, sleeplessness, stress, burnout, trauma reactions and/or
psychiatric illnesses?
Yes
No
Yes
No
8. A condition or illness of the stomach, intestinal tract, gall bladder and/or pancreas
Yes
No
Yes
No
9. A condition or illness of the urinary tract, kidneys, genitals and/or prostate
Yes
No
Yes
No
10. Nutritional, medicinal or insulin treatment for diabetes
Yes
No
Yes
No
11. High blood pressure and/or high cholesterol
Yes
No
Yes
No
12. A condition or illness of the heart, coronary artery and/or other artery?
Yes
No
Yes
No
13. Blood clot/bleeding in the brain and/or another blood vessel
Yes
No
Yes
No
14. Epilepsy, dementia, headaches and/or any other neurological condition or illness?
Yes
No
Yes
No
15. Tumour and/or a disease of the blood and/or lymphatic system?
Yes
No
Yes
No
16. Conditions, symptoms, illnesses, injuries or handicaps not listed in questions 1–15?
Yes
No
Yes
No
17. Are you currently taking medication?
Yes
No
Yes
No
18. Have you taken more than 14 consecutive days of partial or full sick leave in the
past three years?
Yes
No
Yes
No
19. Do you smoke?
Yes
No
Yes
No
20. Please indicate your height and current weight:
cm
kg
cm
kg
Authorisation
I hereby authorise my doctor or other healthcare professionals, hospitals or other health care institutions, employment agencies, the Social Insurance Office or other insurance agencies to provide any information, log entries or attestations required by Förenade Liv for the processing of this insurance application. This authorisation is also valid for claims adjustments after my death and/or in the event of my inability to issue a new authorisation due to illness, personal injury etc. This authorisation will remain valid until it is revoked or until the matter is resolved. If this authorisation is revoked before the matter is resolved, I am aware that revocation may result in rejection of my application or non-payment of the services applied for.
I confirm that all information provided is complete and truthful. I am aware that inaccurate and incomplete information may void my insurance policy. I understand that coverage will take effect only if the application is complete and if the policy is approved by Förenade Liv. Förenade Liv may store any information provided.
Date
Daytime phone (plus dialling code)
Date
Daytime phone (plus dialling code)
Declaration of Health
Supplementary information for question no.
...
of the health declaration
Regarding
Member
Co-insured
If you answered ‘yes’ to more than one question on this health declaration, please copy this form or print more at
www.forenadeliv.se.
Name
Civic registration no.
Group contract no.
What is your occupation and what are your occupational responsibilities?
What is the name of your illness/condition? Your diagnosis?
Describe the condition/symptoms in your own words:
Cause of condition/symptoms (e.g. accident, illness, work-related)
When did your symptom/illness, injury or handicap first appear?
year: month:
Have you had similar complaints before?
Yes
No
If ‘yes,’ when?
What type of treatment/examination did you receive?
When did you last seek medical care?
Please indicate the name and full visiting address (e.g.
department/clinic) of healthcare providers whose services you
have used during the past three years.
Cause identified/diagnosis?
year month
Please indicate your diagnosis and the period of your sick leave as accurately as possible.
From
until Diagnosis:
From
until Diagnosis:
From until Diagnosis:
Please indicate which medicine(s) you are taking:
Will you be seeking additional examination or treatment?
Yes
No
If ‘yes,’ what type?
Are you symptom-free?
Yes No If ‘yes,’ when did you become symptom-free?
year:
month:
If you are not symptom-free, what remaining symptoms/conditions are you experiencing?
Authorisation
I hereby authorise my doctor or other healthcare professionals, hospitals or other health care institutions, employment agencies, the Social Insurance Office or other insurance agencies to provide any information, log entries or attestations required by Förenade Liv for the processing of this insurance application. This authorisation is also valid for claims adjustments after my death and/or in the event of my inability to issue a new authorisation due to illness, personal injury etc. This authorisation will remain valid until it is revoked or until the matter is resolved. If this authorisation is revoked before the matter is resolved, I am aware that revocation may result in rejection of my application or nonpayment of the services applied for.
I confirm that all information provided is complete and truthful. I am aware that inaccurate and incomplete information may void my insurance policy. I understand that coverage will take effect only if the application is complete and if the policy is approved by Förenade Liv. Förenade Liv may store any information provided.
Date
Health Declaration
Child under 18
FLG-693
If the answer to any of questions 4-22 is "Yes", supplementary information must be given on the attached form.
To be completed by a custodian who is applying for child insurance for a child
aged under 18. "Important to know" in "Important information" indicates when a health
declaration needs to be submitted.
The health declaration for a child who has reached the
age of 18 can be found at forenadeliv.se. It is important to answer all questions.
Group agreement number
Name of member/employee (group member)
Civic registration no.
Name of child
Civic registration no.
1. Birth weight (for children aged under 6)
grams
2. Birth week (for children aged under 6)
Week:
3. Present height and weight
cm
kg
4. Were there any complications in connection with labour or during the first month after birth?
Yes No
5. Has anything particular arisen during checks at the children's health centre (BVC) or school health care?
Yes No
6. Does the child receive any special help at childminder/ pre-school/ school?
Yes No
7. Have care contributions been applied for?
Yes No
Have any health care services been used
(e.g. prescription, nursing, treatment, hospital examinations or checks,
health care centre, treatment centre or other care institution, or any other contact made with a doctor or nurse,
physiotherapist etc. due to conditions/symptoms/illness/handicap in respect of any of the organs or conditions
mentioned below)
during the last five years, due to:
8. allergy, asthma?
Yes
No
9. eczema , skin condition, skin disease?
Yes
No
10. metabolic disorder, diabetes?
Yes
No
11. illness/condition of the eye, ear/nose/throat?
Yes
No
12.Musculo-skeletal disorders?
Yes
No
13. mental condition/illness, behavioural disorders (e.g. ADHD, eating disorders)?
Yes
No
14. condition/illness of the stomach, intestines, inner organs?
Yes
No
15. condition/illness of the urinary tract, kidneys?
Yes
No
16.delayed speech development or other delayed development?
Yes
No
17. condition/illness of the heart or vascular system?
Yes
No
18. cerebral haemorrhage or blood clot?
Yes
No
19. epilepsy or other neurological symptoms/illnesses?
Yes
No
20. tumour, diseases of the lymphatic glands or blood?
Yes
No
21. Has the child taken medicine for any condition or illness other than those mentioned above?
Yes
No
22. Does the child have any condition, symptom, illness or injury or handicap other than those mentioned
in questions 1-21?
Yes
No
23. Is the child adopted? If "Yes" attach the result of the adopted child control.
State name and address of children's health centre (BVC):
Yes
No
Declaration
I confirm that the information provided is entirely truthful. I am aware that incorrect or incomplete information could render
the insurance invalid. I am aware that the insurance will only enter into force if the application is complete and insurance
can be granted by Förenade Liv.
Date
Daytime phone (plus dialling code)
Date
Daytime phone (plus dialling code)
Health Declaration
Child under 18
Please copy this form if you have answered Yes to more than one question
Name of child
Civic registration no.
What is the name of the illness/condition? Diagnosis?
When did the symptom, illness, injury or handicap first occur?
year:
month:
What examination/treatment has the child had?
State what medicine(s) the child is taking:
Will there be further check-ups or treatment?
Yes
No
If the answer is "Yes", of what kind?
Is the child free of symptoms?
Yes If the answer is "Yes", when did the child become free of symptoms?
year:
month:
No If the child is not free of symptoms, what injuries/conditions/symptoms remain?
State the name and complete surgery address,
department/clinic of health care services used during
the last 5 years.
Cause/diagnosis?
When was this health care service
last used?
year month
State the name and complete address of the children's health centre
(BVC) to which the child belongs (for children aged under 6).
State the name and complete address of the school health care service
to which the child belongs (for children aged over 6).
Declaration
I confirm that the information provided is entirely truthful. I am aware that incorrect or incomplete information could
render the insurance invalid. I am aware that the insurance will only enter into force if the application is complete and
insurance can be granted by Förenade Liv.
Date
Daytime phone (plus dialling code)
Date
Daytime phone (plus dialling code)
Custodian's signature
Custodian's signature
Supplementary information to question No.
...
forenadeliv.se/sulf
Policyholder’s name Agreement number
Civic registration no. Daytime phone (plus dialling code)
Name of bank Clearing code Account number
If you are paying through an account other than your own, give the payer’s name and civic registration number below.
Name, other payer Civic registration no.
Date Signature (policyholder)
Date Signature (other payer)
I approve the conditions for payment to Förenade Liv by direct debit
Yes! I wish to pay by direct debit
You can also register for d
irect
debit at forenadeliv.se/au
togiro
Conditions for Förenade Liv direct debit
Mandate for payment by direct debit (Autogiro)
The undersigned (”the payer”), consents to payment being made by withdrawal from the account indicated or an account indicated by the payer at a later time on request of the indicated payee for payment to the payee on a certain date (”the due date”) through Autogiro. The payer consents to processing of personal data provided in this mandate being handled by the payer’s payment service provider, the payee, the payee’s payment service provider and Bankgirocentralen BGC AB for the administration of the service. Personal data managers for this personal data processing are the payer’s payment service provider, the payee and the payee’s payment service provider. The payer may at any time request to receive access to or correction of the personal data by contacting the payer’s payment service provider. Further information regarding the processing of personal data in connection with payments may be found in the terms and conditions for the account and in the agreement with the payee. The payer can at any time revoke his or her consent, which concludes the service in its entirety.
Description
GeneralAutogiro is a payment service that means that payments are carried out from the payer’s account on the initiative of the payee. For the payer to be able to pay through Autogiro, the payer must provide his or her consent to the payee that the payee may initiate payments from the payer’s account. In addition, the payer’s payment service provider (e.g. bank or payment institution) must approve that the account can be used for Auto-giro and the payee must approve of the payer as a user of AutoAuto-giro.
The payer’s payment service provider is not obliged to check the authorisation of or noti-fy the payer of requested withdrawals in advance. Withdrawals are charged to the payer’s account in accordance with the rules that apply at the payer’s payment service provider. The payer receives notification of withdrawals from his or her payment service provider. On request of the payer, the mandate can be transferred to another account with the payment service provider or to an account with another payment service provider. Definition of banking business day
A banking business day refers to all days except Saturday, Sunday, Midsummer’s Eve, Christmas Eve or New Year’s Eve or another public holiday.
Information on payment
The payer will be notified by the payee of the amount, due date and means of payment no later than eight banking business days before the due date. This can be notified prior to every individual due date or on one occasion concerning several future due dates. If the notification refers to several future due dates, the notification must be made no later than eight banking business days before the first due date. However, this does not apply to cases in which the payer has approved the withdrawal in conjunction with a purchase
or order of a product or service. In such a case, the payer receives a notice from the payee regarding the amount, due date and means of payment in conjunction with the purchase and/or the order. By signing this mandate, the payer provides his or her consent to payments covered by the payee’s notification in accordance with this section being carried out.
Sufficient funds must be available in the account
The payer must ensure that sufficient funds are available in the account no later than 00:01 on the due date. If the payer does not have sufficient funds in the account on the due date, it may mean that payments cannot be carried out. If sufficient funds are unavailable for payment on the due date, the payee may make additional withdrawal attempts during the coming banking business days. The payer can receive information from the payee upon request regarding the number of withdrawal attempts. Stop payment (revocation of payment order)
The payer may stop a payment by contacting either the payee no later than two banking business days before the due date or his or her payment service provider no later than the banking business day before the due date at the point in time indicated by the pay-ment service provider. If the payer stops a paypay-ment as per the above, it means that the current payment is stopped on a single occasion. If the payer wants all future payments initiated by the payee to be stopped, the payer must revoke the mandate.
Mandate’s period of validity, revocation
The mandate is valid until further notice. The payer has the right to revoke the mandate at any time by contacting the payee or his or her payment service provider. In order to stop payments not yet carried out, the notice of the revocation of the mandate must be received by the payee no later than five banking business days before the due date or be received by the payer’s payment service provider no later than the banking business day before the due date at the point in time indicated by the payment service provider. The right for the payee and the payer’s payment service provider to end the connection to Autogiro.
The payee has the right to end the payer’s connection to Autogiro 30 days after the payee has notified the payer thereof. However, the payee has the right to immediately end the payer’s connection to Autogiro if the payer on repeated occasions does not have a sufficient account balance on the due date, if the account to which the mandate pertains is closed or if the payee deems that the payer should not participate in Autogiro for another reason. The payer’s payment service provider has the right to end the payer’s connection to Autogiro in accordance with the terms that apply between the payer’s payment service provider and the payer.
Förenade Liv Gruppförsäkring AB
106 60 Stockholm
[email protected]
Customer service
Telephone: 08-700 40 80
Fax: 08-700 43 00
Member’s signature
Date Signature Civic registration number
