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

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SECTION B Full application detailsPART 1 – ABOUT YOUClient oneClient twoWhat is your contact address,including postcode?Please check that you have filledin your postcode as this is essentialfor processing the applicationmore quickly.PostcodeAs Client 1PostcodeWhat is your home address,including postcode, if differentfrom the contact addressprovided above?Please check that you havefilled in your postcode.PostcodeAs Client 1PostcodeWhat are your contact details?Please ensure that youcomplete all details.Work phoneHome phoneMobile phoneEmail addressWork phoneHome phoneMobile phoneEmail addressIt may be necessary for us tocontact you to discuss yourapplication, which might includediscussing matters of a sensitivenature. Are you happy for us totelephone you in this event?Please note, we may recordand monitor calls.WORKYesNoIf ‘Yes’, which phone number and time is most suitable?WorkMon-Fri9am-11amMon-Fri2pm-4pmMon-Fri6pm-8pmHomeMon-Fri11am-2pmMon-Fri4pm-6pmMobileYesNoIf ‘Yes’, which phone number and time is most suitable?WorkMon-Fri9am-11amMon-Fri2pm-4pmMon-Fri6pm-8pmHomeMon-Fri11am-2pmMon-Fri4pm-6pmMobileIf you are a houseperson, retired, a student or unemployed, please ignore this question and proceed to the next question.Client oneClient twoDoes your job involve work in anyof the occupations or environmentslisted opposite?If ‘Yes’, please tick all that apply.If ‘No’, please tick ‘None ofthe above’.Outside at heights of over 12 metres (40 ft) for more than 10% of the timeThe Armed Forces or member of the Army ReserveThe offshore fishing industryThe offshore oil or gas industryAs a full time barman, barmaid or landlord in a public houseFull time means working an average of 30 or more hours a week.UnderwaterUnderground, for example mining, tunnellingWith explosivesAs a sports professionalNone of the aboveClient oneClient twoPlease also tell us your job titleif you have ticked one of theoccupations in this question.Job title*Job title**If you have more than one job, please give your main job title only.Page 6Whole of Life Protection Plan – Application Form and Additional Questionnaires
SECTION B Full application details continuedTOTAL COVERClient oneClient twoIncluding this application, will thetotal amount of LIFE cover on yourlife exceed £1,500,000?Yes No Yes NoIf you have answered ‘Yes’ to the above question and this cover is for Business reasons please complete a Business AssuranceQuestionnaire (W1844) available on the Adviser Centre; you can copy this link into your browser: http://www.legalandgeneral.com/library/underwriting/underwriting-questionnaire/W1844.pdf, otherwise please complete a Personal Assurance Questionnaire (in Part 4)BEFORE continuing with the next question.TRAVELClient oneClient twoDuring the last five years haveyou lived, worked or travelledOUTSIDE the UK?Please ignore holidays for up toone month; business trips up toone week, provided they did nottotal more than 12 weeks in a year.In this context, UK includesEngland, Scotland, Wales,Northern Ireland, Isle of Manand the Channel Islands.YesNoIf ‘Yes’, please give the following details:Which country?In total, how longwere you there? years monthsHow long ago wasyour last visit? years monthsYesNoIf ‘Yes’, please give the following details:Which country?In total, how longwere you there? years monthsHow long ago wasyour last visit? years monthsDo you have anyother country(ies)to disclose?YesNoDo you have anyother country(ies)to disclose?YesNoIf ‘Yes’, please give the same details as above, for theother country(ies), in Part 8 (Additional Information)before continuing with this section.If ‘Yes’, please give the same details as above, for theother country(ies), in Part 8 (Additional Information)before continuing with this section.During the next two years, doyou intend to live, work or travelOUTSIDE the UK?Please ignore: holidays for up toone month; business trips up toone week, provided they will nottotal more than 12 weeks in a year;any service as a member of theArmed Forces.In this context, UK includesEngland, Scotland, Wales andNorthern Ireland.YesNoIf ‘Yes’, please give the following details:Do you plan to leave theUK permanently?YesNoIf ‘Yes’, please advise when you plan to leave the UKand where you will live.If ‘No’, will you be staying within the EuropeanUnion, United States of America, Canada,Australia or New Zealand?YesNoIf ‘Yes’, please give the following details:Do you plan to leave theUK permanently?YesNoIf ‘Yes’, please advise when you plan to leave the UKand where you will live.If ‘No’, will you be staying within the EuropeanUnion, United States of America, Canada, Australiaor New Zealand?YesNoYesNoHow long do you plan to be outside the UK orRepublic of Ireland during the next two years?How long do you plan to be outside the UK orRepublic of Ireland during the next two years?weeksdaysweeksdaysPlease list all the countries or islands outside theEuropean Union, United States of America, Canada,Australia or New Zealand that you are going to:Please list all the countries or islands outside theEuropean Union, United States of America, Canada,Australia or New Zealand that you are going to:Whole of Life Protection Plan – Application Form and Additional Questionnaires Page 7
Page 1 and 2: WHOLE OF LIFE PROTECTION PLANCONFID
Page 3 and 4: Your personal and medical informati
Page 5: About your plan continuedClient one
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 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

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

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