Telephone application

Important Notes and Declarations

IMPORTANT NOTES The plan won’t start until we’ve assessed and accepted your application, and the first premium has been paid. If you have a birthday while your application is being processed, the terms may differ from those originally quoted to you. In most instances your premiums will be as originally quoted. We may offer you revised terms, but occasionally we may not be able to offer any terms. We may ask you to contact your doctor if we’re waiting for reports which we’ve asked for. If we ask you to come for a medical examination, we’ll need to share the application information with another company we’ve authorised. They will make the arrangements for the examination to take place.

We may need to send your application and relevant medical reports to our reinsurers for their opinion or agreement of the terms offered. Or, we may need to send them at a later stage for purposes relating to managing your policies. You can get details of general reassurance principles and details of any company we use to assess your application, from our Head Office. We have a confidentiality policy in place which means we hold your medical information securely and access is limited to authorised individuals who need to see it. You’re entitled to ask for a copy of our standard terms and conditions and a copy of your application form at any time.

Genetic Test Results For this application we don’t need to know about any genetic test result subject to the sum insured being within the following limits: £500,000 or less for life insurance £300,000 or less for critical illness insurance £30,000 or less for income protection. Above these limits, you may need to tell us about certain genetic test results. We’ll only be interested in genetic test results where the Government’s Genetics and Insurance Committee has approved them for insurers to use. If you think this may apply to you, please ask us for details of the current position. In all cases, you must tell us if you’re experiencing symptoms of, or having treatment for, a genetic condition. For a genetic condition present in the immediate family, it will be worthwhile to tell us of a negative test for the same condition. Details of the Association of British Insurer’s Code of Practice in relation to genetic testing and insurance are available on request. Access to Medical Reports We may need to get medical reports to support your application. Before we can ask any doctor that you’ve consulted to fill in a report, we need your permission under the Access to Medical Reports Act 1988. Your rights under the act are as follows. You don’t need to give your permission, but if you don’t, we may not be able to go ahead with your application. This doesn’t prevent you from applying to other companies for insurance. You can ask to see the report before the doctor returns it to us. If this is the case, we’ll tell the doctor to keep the report for 21 days so that you can arrange to see it. If you haven’t made arrangements to see the report within this time, your doctor will send the report to us. If you choose not to see the report at this stage, you may ask the doctor for a copy within six months of it being sent to us. We can send a copy of the report to your doctor if you ask to see it at a later date. If you think that any part of the report is not correct or is misleading, you may ask the doctor to change it. If your doctor refuses to make the changes, you may ask them to attach a statement outlining your views, which will then accompany the report. Your doctor can withhold access to the report if they feel that it would cause physical or mental harm to you or others.

The medical report your doctor fills in asks about the following: Your current health. any care, medication or treatment you’re currently receiving. the results of referrals or tests you’re waiting for. Any time off work in the last three years. Your past health. details of any relevant illness, trauma, or referrals for specialist advice or treatment, hospital admissions, consultations with your GP or any other medical adviser, therapist or counsellor, in particular whether you have a history of: malignancy (cancer), cardiovascular (heart) disease, diabetes, and degenerative (gradually worsening) diseases; musculoskeletal disease or injury, for example, arthritis, rheumatism, back problems or any other disorder of the joints or muscles; anxiety, depression, neurosis (such as phobias, obsessions and so on), psychosis (a mental disorder where you lose contact with reality), stress or fatigue; suicidal thoughts or attempts at suicide; or conditions related to drug or alcohol misuse or smoking or chewing tobacco. details of any biopsies, blood tests, electrocardiograms (heart tests), height, weight if measured in the last two years, urinalyses (tests on urine), x-rays or other investigations. any blood pressure readings in the last three years. Any history of disease among your parents or brothers or sisters that you’ve told your doctor about. We’ve asked your doctor not to reveal information about: negative tests for HIV, hepatitis B or C; any sexually-transmitted diseases unless there could be long-term effects on your health; or predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from. The information you and your doctor provide about your health may result in us: refusing to provide insurance; increasing premiums above standard rates; or setting premiums at standard rates. If you have any questions about your rights under the act or questions relating to the process of getting, assessing or storing medical information, please write to: LV=, Pynes Hill House, Rydon Lane, Exeter EX2 5SP

Declaration I agree to you asking any doctor I have consulted about my physical or mental health to provide medical information so you may assess my application. You may gather relevant information from other insurers about any other applications for life, critical illness, sickness, disability, accident or private medical insurance that I have applied for. I authorise those asked to provide medical information when they see a copy of this consent form. This declaration allows you to gather medical reports within six months of the start of the plan, or after my death, to support any claim made on the plan proceeds. This information can also be used to maintain management information for business analysis. By signing this declaration I am allowing you to process my application using the information that I have given. You may also use this information to process any claims made on the policies I have applied for. You should not assume that we’ll write to your doctor for a report, although we may do so. Please ensure that you answer all the questions truthfully and accurately.

We MUST be informed of any changes in your health, occupation duties or other information provided in this application which take place before any of the policies you’ve applied for start. For example you must tell us if you’ve had any medical consultations, advice, treatment, or investigations, or if you’ve changed job, or the main duties that you carry out as part of your job have changed. If you don’t tell us, we may not pay a claim, and could cancel your policies.

Please be aware that we may not pay a claim, and could cancel your policies if you do not answer all of the questions in this application truthfully and accurately.

Whilst the vast majority of our customers are honest we do have to protect ourselves (and all of our customers) against the effect of fraudulent claims. As part of our ongoing quality control process we continually monitor all completed applications to help ensure that the information provided is correct, and that people haven’t deliberately provided us with false or misleading information.

We do this by reviewing a random sample of applications to ensure that the policies were correctly underwritten by us, and that we have received all of the information we asked for during the application process. If your application is selected, we will write to your general practitioner to ask for a medical report. We’ll use these Declarations you have signed as it authorises us to contact your general practitioner (GP). The declaration in this application explains your rights under the Access to Medical Reports Act 1988 (AMRA).

Declaration I am aware that all the people involved in this application must sign this declaration. For the person or people insured, they must also sign the summary of any interviews that may be required for the purposes of underwriting the policies applied for. If all signatures aren’t received within 60 days from the start of the plan, Liverpool Victoria Friendly Society Limited (LV=) may cancel the plan and no premiums will be refunded. I wish to enter into a contract for the policies noted in this application on LV= normal terms and conditions. I hereby declare that my answers in this application are true and complete and that I haven’t knowingly withheld or concealed any information that LV= has asked for. I’m aware that if I have then my plan could be cancelled and that LV= may not pay a claim. I acknowledge that any policy which LV= may issue to me is based on the information in this application, the answers in my medical report(s), if any, and this declaration. I will tell LV= immediately of any changes in my health, occupational duties or other information provided to LV= that happen before the policies I have applied for start. I am aware that LV= must be told about these changes, and if I don’t tell LV= about them, I’m aware that my plan may be cancelled, and that a claim may not be paid. To the best of my knowledge and belief all the statements made, which includes anything I may have said, have been recorded accurately in this application and are true and complete. This disclosure will form the basis of the contract.

I agree to LV= seeking medical information from any doctor who at any time has attended me concerning anything which affects my physical or mental health, in order to assess my application. You may also seek relevant information from other insurers about previous or current applications for life, critical illness or income protection insurance that I have applied for. I authorise those asked for such information to provide it on the production of a copy of this consent. This consent allows LV= to obtain medical reports at any time during the life of the policies applied for or after my death to support any claim made on the policy proceeds. I agree that LV= can use any sensitive information I provide, such as health and medical information, to process my application and for the ongoing management of my policies. This information may be passed on to: my GP any medical practitioner and/or health care professional acting for LV= reinsurers or any other insurer I’ve applied and given consent to my financial adviser any associated company of LV= I agree to LV= accepting medical reports faxed directly to LV= from my doctor’s surgery. I also do not object to copies of the report being faxed to any of those parties to whom LV= may disclose personal data, as stated above, at their request.

In the event of a claim I am aware that my names, dates of birth and post code will be provided to the Association of British Insurers (ABI) Health Claims database which has been set up to deter/prevent fraud. LV= may use information given to make searches about me at credit reference agencies that hold my information (such as from the electoral roll). The agencies check my identity and will keep records of these searches, even if my application doesn’t go ahead. I am aware that LV= may use scoring methods to check my identity and may ask me for supporting documents. I may be contacted by telephone, post or other electronic methods. LV= may use information provided to process my application and manage my plan. The information may be kept electronically or on paper file for as long as the application is being considered, while the policies applied for are active and for an appropriate length of time after that. LV= will keep my information and add it their customer databases even if my application doesn’t go ahead. LV= may use it to keep their records up to date, for business analysis and market research. LV= may pass my details to other carefully selected organisations, but only for the purposes listed here. Subject to the payment of a fee, if you’d like LV= to send you a copy of the personal information we hold about you, please write to: CCA Department, LV=, County Gates, Bournemouth, BH1 2NF. For more information about the LV= group of companies please go to www.lv.com.

I confirm that LV= advised me/us to read the Important Notes and Declaration and information relating to my rights under the Access to Medical Reports Act. I agree that by accepting this Declaration that I am bound by it.