Whole of Life Application Form (W10243) - Legal & General

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FAMILY HISTORY continuedClient oneClient twoIf you don’t know the details ofthe medical history of your parents,brothers and sisters please tellus why.Don’t know – AdoptedNo further contact with family membersDon’t know – OtherIf ‘Other’, please give detailsDon’t know – AdoptedNo further contact with family membersDon’t know – OtherIf ‘Other’, please give detailsPART 3 – ABOUT YOUR POLICYIs this policy that you’re applying forreplacing any existing policies heldwith Legal & General?We may need to get authority tocancel the policy if it is in trust orowned by someone else.YesNoIf ‘Yes’, what is the policy number(s) of your existingLegal & General policy(ies) that will be replaced?YesNoIf ‘Yes’, what is the policy number(s) of your existingLegal & General policy(ies) that will be replaced?Is this policy that you’re applyingfor to be issued under Trust?YesNoIf ‘Yes’, which policy(ies)?YesNoIf ‘Yes’, which policy(ies)?If you have answered ‘Yes’ to the above question, please contact your Financial Adviser about the type of trust most appropriate to you andyour circumstances.Is this policy that you’re applyingfor to be owned by anotherindividual or company?YesNoIf ‘Yes’, which policy(ies)?YesNoIf ‘Yes’, which policy(ies)?If you have answered ‘Yes’ to the above question, please fill out your doctor’s details below, then complete a Policy Owner Questionnairefor each policy (Part 7) BEFORE going straight to Part 9.Doctor’s detailsPlease include your doctor’spractice name or clinic, postcodeand telephone number as thisis essential for processing yourapplication more quickly.Doctor’s namePractice/clinic name and address(including postcode)Doctor’s namePractice/clinic name and address(including postcode)AsClient 1Please don’t assume that wewill contact your doctor forconfirmation of medical details.PostcodePostcodeTelephone numberTelephone numberThis now completes the mandatory question and answer part of your application.The following green sections are all additional questionnaires which you only need to complete if we’ve asked you to in one of theprevious questions, or if you need to provide us with additional information. Please now ensure you read and sign the Client Declarationand Consent in Part 9 and complete the Direct Debit instruction in Part 10.Page 12Whole of Life Protection Plan – Application Form and Additional Questionnaires
PART 4 – PERSONAL ASSURANCE QUESTIONNAIREThis questionnaire only applies if you have answered ‘Yes’ to the Total Cover question on page 7.Client oneClient two1. Do you have, or are you applyingfor, any other Life cover withanother insurance company?This includes any Life coverprovided by your employer.If ‘Yes’ and you need morespace, please use the AdditionalInformation section in Part 8.Yes NoIf ‘Yes’, please give details:CompanyStart datePolicy typeYes NoIf ‘Yes’, please give details:CompanyStart datePolicy typeTermyearsTermyearsAmount of cover £Amount of cover £Reason for coverReason for coverWill this policy remain Yes Noin force/be going ahead?Do you have any other Yes Nopolicy(ies) to disclose?If ‘Yes’, please give the same details as above for theother policy(ies), in Part 8 (Additional Information)before continuing with this section.Will this policy remainin force/be going ahead?Do you have any otherpolicy(ies) to disclose?YesYesNoNoIf ‘Yes’, please give the same details as above for theother policy(ies), in Part 8 (Additional Information)before continuing with this section.2. Please give details of yourgross annual earned incomefor the last three years.Do not include anyunearned income, suchas investment income.Current yearLast yearPrevious yearEarnedIncome £EarnedIncome £EarnedIncome £Current yearLast yearPrevious yearEarnedIncome £EarnedIncome £EarnedIncome £If you are self employed – please give net taxable earnings after deduction of allowable business expenses.If your earned income for the current year is less than £10,000, please continue with the next question.Otherwise, please skip the next question.3. Please give details of all otherhousehold gross annual earnedincome for the last three years.Current yearLast yearEarnedIncome £EarnedIncome £Current yearLast yearEarnedIncome £EarnedIncome £Previous yearEarnedIncome £ £Previous yearEarnedIncome £4. What is the total value of yournet assets?£‘Net assets’ are your total assets (for example house, car, shares), less your total liabilities (for examplemortgage, outstanding debt). Where examples are shown, they are not intended to be a complete list.Whole of Life Protection Plan – Application Form and Additional Questionnaires Page 13
Page 1 and 2: WHOLE OF LIFE PROTECTION PLANCONFID
Page 3 and 4: Your personal and medical informati
Page 5 and 6: About your plan continuedClient one
Page 7 and 8: SECTION B Full application details
Page 9 and 10: PART 2 - GENERAL HEALTH AND LIFESTY
Page 11: FAMILY HISTORYClient one3No. ofrela
Page 15 and 16: PART 5 - HAZARDOUS PURSUITS QUESTIO
Page 17 and 18: MEDICAL QUESTIONNAIRE 2Use this pag
Page 19 and 20: PART 7 - POLICY OWNER QUESTIONNAIRE
Page 21 and 22: PART 9 - CLIENT DECLARATION AND CON
Page 23 and 24: PART 10A - SAR MEDICAL CONSENT FORM
Page 25 and 26: PART 10B - SAR MEDICAL CONSENT FORM
Page 27 and 28: ✁PART 11 - DIRECT DEBIT INSTRUCTI

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