DECLARATION OF HEALTH
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1 DECLARATION OF HEALTH Please answer all of the questions on this form honestly and in full. If you miss any information out, or give us misleading information, this could mean that we won t pay if you have to make a claim. It could also delay the processing of your application. If you re not sure whether to include any information, then please include it. The information you gave us on your original application form will still form part of your contract with Royal London. If any of the information has changed from your original application form you must tell us on this form. This declaration of health form, together with your original application form, your quote and plan details, will then form the basis of your proposed contract with Royal London. If any of the information you give us on this form affects the application, Royal London will then have the right to reconsider or withdraw terms if appropriate. Please contact us if you need reminding of the information you put in your application form and would like us to send you a copy. It s very important that you tell us if there s a change to any of the answers to the questions within the application (including in relation to the person covered s health, occupation or leisure activities) or any other information you or the person covered provide between the date the answer or information is provided and the date we start the plan. If you need more space for any information, please use the last page of this form. Section 1 About the people covered Title Mr Mrs Miss Ms Mr Mrs Miss Ms Other (please give details) Other (please give details) First name(s) Surname Date of birth D D M M Y Y Y Y Plan number (if known) Date of application (if applicable) D D M M Y Y Y Y Since you completed your original application form have you applied for any other cover with any other insurance company? Protection
2 Section 2 Your job, leisure activities and lifestyle application form has there been any change to the country in which you are permanently resident? In the next 6 months, will you be moving from the country in which you are permanently resident? Has there been any change in your job, or the activities involved in your job, since you completed your original application form? e.g. you now work at heights, your job now involves hazardous duties or an increase in manual or driving work. Have you become a member of the TA or Armed Forces reservists since you completed your original application form? application form have you taken up any hazardous leisure activities? e.g. aviation, caving or potholing, hang-gliding, motor sports, mountaineering or rock climbing, parachuting, underwater diving or yachting. Have you smoked or used any tobacco, nicotine replacement products or e-cigarettes in the last 12 months? If you answer No, we may carry out tests to check that you are a non-smoker. If Yes, please tell us how much you smoke a day. Yes No Cigarettes a day Cigars a day Pipes a day Nicotine replacement products E-cigarettes Other If Other, please give details Yes Cigarettes a day Cigars a day Pipes a day Nicotine replacement products E-cigarettes Other No If Other, please give details Since you competed your original application form have you had a positive test for HIV/AIDS or Hepatitis B or C, or are you awaiting the results of such a test? If the results of a test you re waiting for turn out to be negative, the fact that you had a test won t affect the acceptance terms we offer you. Page 2 of 6
3 Section 3 Your health What is your height? You can use either feet and inches or metres and centimetres. What is your weight? You can use either stones and pounds or kilograms. What is your current trouser size, UK dress size or skirt size? If you re pregnant, please tell us your size immediately before your pregnancy. application form: have you become certified by a doctor as unfit for work? are you experiencing any symptoms or complaints for which you have not consulted a doctor? For example: A mole/blemish which has changed in appearance Any lump, growth, swelling or hardening affecting the skin, breasts or testicles Bleeding from the bowels, change in bowel habit Persistent cough Weight loss or unexplained bleeding Onset of fits or seizures Dizziness, blackouts/fainting are you awaiting, or have you been advised to seek, any medical or surgical consultation or follow-up? Tick Yes if you are awaiting an appointment with your GP ft in or m cm ft in or m cm st lbs or kg st lbs or kg application form have you: attended any other medical appointment taken any other test or medication, or received any other treatment? Tick Yes even if you are awaiting any medical or surgical test, consultation or follow-up, including the results of any such test. You don t need to tell us about any of the following treatments and confirmed conditions: acne, athlete s foot, blisters, cold sores, common colds, conjunctivitis, contraception, ear wax or syringing, food poisoning, hay fever, infected or extracted wisdom teeth, infertility treatment, influenza, ingrowing toenails, miscarriage, pregnancy, shingles, sinus trouble, tonsillitis, vaccinations or vasectomy. Page 3 of 6
4 Section 4 Declaration of health I declare that: I agree that: I understand that: the answers I have given are true and complete, to the best of my knowledge and belief if I have applied as a non-smoker that I have not used any form of tobacco, e-cigarettes or nicotine replacement products in the last 12 months. if my health changes, or any other detail affecting the application changes, before the date Royal London assumes risk on the plan, or the plan restarts or changes, I will inform Royal London in writing. I understand Royal London will then have the right to reconsider terms if appropriate. this declaration of health form, together with your original application form, and the plan details, will set out the terms of your proposed contract with Royal London. if any detail affecting the application changes before the date Royal London assumes risk on the plan, or the plan restarts or changes, Royal London will then have the right to reconsider or withdraw terms if appropriate. if I do not give Royal London all facts that are likely to influence the assessment and acceptance of this application form, any plan issued as a result of this application may be cancelled or the terms changed, and any claims may be refused. Royal London may request medical information within 6 months of the start of the plan to check the accuracy of any statement made in, or in connection with, this application. If the person covered does not give their consent to Royal London obtaining this information, or any statement is inaccurate and this affects Royal London s assessment of the insurance risk, Royal London will then have the right to reconsider or withdraw terms if appropriate and my plan may be cancelled. Signature Date D D M M Y Y Y Y D D M M Y Y Y Y Please return this form to: Royal London, 1 Thistle Street, Edinburgh EH2 1DG Page 4 of 6
5 Section 5 Additional information If you need more space for any answers please use this area and include the relevant question number. If you still need more space please use an additional sheet of paper. Remember to write your plan number or full name and date of birth on any additional sheets of paper and sign, date and attach it securely to the declaration of health. Page 5 of 6
6 Royal London 1 Thistle Street, Edinburgh EH2 1DG royallondon.com All literature about products that carry the Royal London brand is available in large print format on request to the Marketing Department at Royal London, 1 Thistle Street, Edinburgh EH2 1DG. All of our printed products are produced on stock which is from FSC certified forests. The Royal London Mutual Insurance Society Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. The firm is on the Financial Services Register, registration number It provides life assurance and pensions. Registered in England and Wales number Registered office: 55 Gracechurch Street, London, EC3V 0RL. Royal London Marketing Limited is authorised and regulated by the Financial Conduct Authority and introduces Royal London s customers to other insurance companies. The firm is on the Financial Services Register, registration number Registered in England and Wales number Registered office: 55 Gracechurch Street, London, EC3V 0RL. February 2017
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