Enhanced Pension Annuity Quotation Request Form

Enhanced Pension Annuity Quotation Request Form

Important notes

Please describe as much information about your health as possible before signing this form. All questions asked are relevant, and by providing full and accurate information you will allow an insurer to provide as accurate a quotation as possible. The amount of your annuity income will be based on the medical information supplied. However an insurer may also seek to obtain independent verification of this information from your doctor. If it is subsequently found that the questions were not answered accurately and with reasonable care, then that could result in your income being reduced or your policy being cancelled.

You/Dependant to complete sections 1+2. Financial Adviser to complete sections 3+4.

Section 1: Personal Details

Home address:

Postcode:

Daytime telephone number:

Evening telephone number:

E-mail address:

Quote Reference No. (if applicable):

Source of quote:

Has Power of Attorney been vested in another party? Yes No

If so which type?

Section 2: Medical Assessment Form

Please ensure that all details entered are accurate to improve your benefits.

Height:

Weight:

Waist measurement:

Do you currently smoke? Yes No

If yes, please advise year started:

Have you been a regular daily smoker for the last 10 years? Yes No

If you are a regular smoker, average daily level:

If you are a regular smoker, average weekly level:

If you previously smoked, years started and stopped:

How much did you smoke?

How many units of alcohol do you drink weekly?

Have you been diagnosed with high blood pressure? Yes No

Have you been diagnosed with high cholesterol? Yes No

Please provide any other medical information relevant to your application:

Medical Conditions

If you have ever been diagnosed with any of the following, please only complete the relevant questionnaire(s): Heart condition, Diabetes, Cancer, Stroke, Respiratory/lung disease, Multiple sclerosis, Neurological disease.

Condition 1:

Condition 2:

Condition 3:

Date first diagnosed / last symptoms / last treatment / last admitted (for relevant condition):

Heart attack, angina and other heart conditions questionnaire

Please indicate who is completing: You Your Dependant

Diagnosed with:

Date of diagnosis:

Current medication:

Diabetes questionnaire

Please indicate who is completing: You Your Dependant

Date diagnosed:

Type: Type 1 Type 2

Control method: Diet only Non-insulin Insulin

Current medication:

Cancer, leukaemia, lymphoma, growth or tumour questionnaire

Please indicate who is completing: You Your Dependant

Type of tumour / malignant condition:

Location:

Date first diagnosed:

Nature of tumour:

Benign

Pre-cancerous

Malignant

Further details:

Stroke questionnaire

Please indicate who is completing: You Your Dependant

Type of stroke:

Date:

Ongoing problems:

Speech difficulties

Vision impairment

Paralysis arm

Paralysis leg

Short-term memory loss

Respiratory/lung disease questionnaire

Please indicate who is completing: You Your Dependant

Diagnosed with:

Date of diagnosis:

Current medication:

Multiple sclerosis questionnaire

Please indicate who is completing: You Your Dependant

Date diagnosed:

Subtype:

Current medication:

Other neurological condition questionnaire

Please indicate who is completing: You Your Dependant

Diagnosed with:

Date of diagnosis:

MMSE score if known:

Current medication:

Activities of Daily Living (ADL) questionnaire

Please indicate who is completing: You Your Dependant

Relevant diagnosis:

Please advise your current condition in the areas below:

Declaration and Consent

Please read, complete and sign this section.

I/We declare that the information and statements provided are true and I/we have taken reasonable care to ensure that my/our answers are correct.

I/We agree that the Provider may obtain medical information and apply for medical evidence.

I/We agree to the Provider processing my/our medical data.

Providers requested: Aviva Canada Life Just Retirement Legal & General LV= Partnership Prudential Retirement Advantage

Section 3: Financial Adviser’s Details

Basis of sale: Advised – Independent Advised – Restricted Advised – Simplified Non-Advised – Execution Only Non-Advised – No Advice Non-Advised – Direct Offer

Name of Firm:

Contact Name:

RI/Adviser Name:

Company Address:

Postcode:

E-mail:

PRA/FCA Reference Number:

Telephone Number:

Facsimile Number:

Initial adviser charge:

Ongoing adviser charge:

Commission:

How would you prefer to receive the quote? Post Fax Email

Section 4: Pension Details

Total purchase price:

Net amount after PCLS:

Income required:

Source of funds:

Name of ceding pension provider/s:

Pension commencement lump sum required? Yes No

If yes, amount:

Registered pension scheme: Yes No

Death in service: Yes No

Pensions credit: Yes No

Assumed annuity commencement date:

Pension benefits:

Annuity options:

Yearly Half Yearly Quarterly Monthly

In advance In arrears

With proportion Without proportion

With overlap Without overlap

Escalation: 3% 5% RPI LPI Other

Guarantee: None 5 Years 10 Years Other

Payable as lump sum, if possible: Yes No

Value protection:

Value protection (joint lives): Payment on spouse death Payment on annuitant’s death

With dependant’s benefit: Yes No

% dependant’s benefit on death:

Ceasing on remarriage: Yes No

Single life and joint life: Yes No

Investment linked annuity quotations? Yes No

Level of return to be assumed:

For unit linked products, % benchmark:

Number of illustrations expected:

If above LTA, level of protection: