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

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Page 22Whole of Life Protection Plan – Application Form and Additional Questionnaires
PART 10A – SAR MEDICAL CONSENT FORM FOR CLIENT ONE.PATIENT REPRESENTATIVE AUTHORITY CONSENT FORMACCESS TO HEALTH RECORDS UNDER THE DATA PROTECTION ACT 1998 (SUBJECT ACCESS REQUEST).PLEASE COMPLETE, SIGN AND DATE THIS SUBJECT ACCESS REQUEST FORM.Patients authority for release of health records (Manual or Computerised Health Records)Details of the Data Subject(the person to whom theinformation relates).Full name:Date of Birth:D D M M Y Y Y YDear Doctor,I authorise Legal & General Assurance Society Limited to apply for a copy of my full health records (excluding predictive genetic test results) under theData Protection Act 1998 (the Act) within 12 months of the signature date and in order to process any future claim.I authorise you to provide the information in the format they request and to send the information directly to them.This is in addition to any other subject access requests I may have made previously.Signature:Date:D D M M Y Y Y YWhole of Life Protection Plan – Application Form and Additional Questionnaires Page 23
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 and 12: FAMILY HISTORYClient one3No. ofrela
Page 13 and 14: PART 4 - PERSONAL ASSURANCE QUESTIO
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: PART 9 - CLIENT DECLARATION AND CON
Page 25 and 26: PART 10B - SAR MEDICAL CONSENT FORM
Page 27 and 28: ✁PART 11 - DIRECT DEBIT INSTRUCTI

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