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SECTION A Client and product details

Initial Client details
Client one
i a. Full name and title riddle nicies Mi, Mrs, Miss Ms Or, Rev, Other middle name(s) in full

Client two
Mr, Mis, Miss, Ms, Dr, Rev, Other middle name(s) in full

Surname

Surname

Male ' c. Date of birth

Female

\

| Male

Female

\
Yes

|
No

j

1 =

1 I*
Part time wod!^ Retited Houseperson Student :

; , e.

pipes, or nicotine replacements in the last 12 months - including occasional use? Employment status

Full time employee Self employed Unemployed

Part lime employee Retired House person

Contract worker
M

: Fulltime i employee employed Unemployed

«n<

useperso*. 'OTre^, o v^aen

Client one
a. Please indicate your occupation from the categories listed .i.yo.roccupctondoMm.i,™ Working in an office-type environment for at least 75% of your typical working day Retail - for example, salesperson, refailer, shop worker or manager, (except market traders) Catering - for example, caterer, chef, cook, waiter, waitress, kitchen staff Education - for example, teacher, lecturer, head teacher, classroom assistant, nursery worker surgical, carer Another category (including market traders) tf 'Healthcare', please selec auxiliary, paramedic, practice nu se, dental nurse, district nurse, midwife Surgeon, anaesthetist, obsletricia n, gynaecologist, dentist, dental hygienist, carer, ca re assistant, social worker, physiotherapist ctitioner hospital doctor (other than surgeon, anae sthetist, e above). psychiatrist, osteopath If 'Another category', pleose give details: ! 1

Client two
Working in an office-type enviro ment for at least 75% of your typical working day Retail - for example, salesperson retailer, shop worker or manager, (except ma <et traders) chef, cook, waiter, waitress, kitchen staff Education - for example, teache lecturer, head teacher, classroom assistant, nurs ;ry worker Healthcare - for example, nursin g, medical. surgical, carer Another category (including ma ket traders) If 'Healthcare', please select: Nurse, staff nurse, charge nurse, s stei, mat re auxiliary, paramedic, practice nu se, denta nurse, district nurse, midwife Surgeon, anaesthetist, obstetricia n, gynaecologist, dentist, dental hygienist, carer, ca re assistant, social worker, physiotherapist Physician, medical or general pro ctitioner, h ospiial sthetist, obstetrician or gynaecologist - se e above), psychiatrist, osteopath If 'Another category', please

th<*ya,enotWe,,dedtobea complete list

OLP Connect 4/35

why are you completing this current application? To replace the other application or policy purposes only For other purposes If 'For other purposes'. how long were you there? was your lasf visit? other coun!ry(ies) to disclose? ' yec If 'For other purposes'. as applicable.Client one Does your job.Business Assurance Questionnaire [Part 5). in Part 9 (Additional Information) before continuing with this section OLP Connect 12/35 . please tick 'None of the above' The offshore fishing industry The offshore oil or gas production industry a full time barn a public house Client two 1 The Armed Fore The offshore fishing industry The offshore oil or gas production industry As a full time barman. tunnelling i sports professional None of the above Please also tell us your job title if yen haven't toid us already in this form and you have ticked one of the occupations in this question i sports prc e of the abovi Is the total cover with Legal & General on your life greater than £800. please tick all that appfy If 'No'. or jobs if you hove s thai wolvt ! The Aimed Forces listed opposite? tf 'Yes'. what is the amount of c in total under the other application(s)? Lite Cover Critical Illness Cover (monthlyamount) £ £ £ £ E 1i If 'Yes'. please give the same details as above. what is the amount of caver in total under the other application^}? Life Cover Critical Illness Cover !mCo°nThV^ 10 In the fast 5 years have you lived. Have you taken out any Life or Critical illness cover or Income Profection Benefit with ANOTHER insurer in the lost 12 months? (Please any application that you didn't proceed with) If 'Yes'. Which country? « " Yes months months No In total. why are you completing this current application? To replace the other application or policy For comparison For other purposes If 'Yes'. please give the following details: trips up to ! week. BEFORE continuing with question 9: U . provided they w not total more than 12 weeks in a year) Which country? In total.000 for Life cover or £500.Personal Assurance Questionnaire [Part 4). tor the other countryfies). for example mining. bai in a public house Underground. please give the same details as above. months No If 'Yes'. please complete the following questionnaire(s). and/or . if you're applying for Business Protection. for the other country(ies).000 for Critical Illness cover? If you hove answered 'Yes' to question 8. please give the following details. if you're applying for Family Protection or Mortgage Protection. worked or travelled OUTSIDE the UK? (Please ignore the following: tf 'Yes'. in Part 9 (Additional Information) before continuing with this section Q ff 'Yes'. how long were you there7 was your last visit? Do you have any other country(ies) to disclose? " years y month.

or you intend to do so within the next 6 months. ^dS00' Sailing Powe.a^: If -No'. Canada. please give the following details: N f 'Yes'. for example bungee or BASE jumping. will you be staying within the European Union. business not total more than 12 weeks in o year. Australia or New Zealand? How long do you plan to be outside the UK in the next 2 years? ' 1 Yes 1 No If 'No'.: ""<"• na r. racing Underwater diving . work or travel OUTSIDE the UK? holidays for up to 1 month. Australia or New Zealand that you are going to: I 1 12 If you regularly take part in any of the activities listed opposite. will you be staying within the European Union. please advise when you intend to go and where you will live If 'Yes'. white water rafting None of the above i-iy ng 'OIRPI than as a 'tre-paync. for example bungee or BASE None of the above Whe !e c .ng Flying (other than as a fare-paying passenger Hang gliding Mountaineering or Rock climbing Mountaineering o. Australia or New Zealand'? How long do you plan to be outside the UK in the next 2 years? j [ ' yes No Weeks Days Weeks Days Please list all the countries of islands outside the European Union.Client one 1 1 During the next 2 years.boa. iuits Questionnaire (Part 6) BEFORE continuing with OLP Connect 13/35 . canyoning. please now continue with Port 2. _~!~d u l^c-Man^-arhPC-r^rells.tal. passenger) T Jv'dos av c-'iO'-i e'ther a. Australia or New Zealand that you are going o: Please list all the countries or islands outside the European Union.. please advise when you intend to go and where you will live ^--t!-'n" w-V -Ir^-". any service as a member of the Armed Forces) Yes No LYes _J^° 1 f 'Yes'. please complete the Hazardous Part 2. please tick all that apply. United States of America. aen t nt^nded to be c Any Extreme sport. If none of these apply. Canada.*vp= .-ih'irr n lf you have ticked any of the activities listed in question 12.Rock climbing: S^"™ Sailing Pcwerboa. please give the following details: Do you plan to leave the UK permanently? j | Y Yes ° Do you plan to leave the UK permanently? y N If 'Yes'. racing Underwater diving Any Extreme sport.•j!— for -iv. a cc^ime or -JE porf o^ ar> Of veH-i.> w nr in-. United States of America. do you intend to live. please tick Caving or Potholing or cabin crew)* Hang gliding Motor car sport*" Motorcycle sport" coving or Po. If you have ticked 'None of the above'.

smoke on average each day? What is your average weekly I Av raa~nu™"h f" j cigarettes smoked a day | cigarettes smoked a day 4 j Average number of Unlts. we'll be willing to consider this when setting your premium. please give the following details: If 'Yes'. | Average number of unit 5 In the last 5 years has your averagi higher than your current average? tf 'Yes'. Ihis is because Ihe Governments Genetics and Insurance Committee (GAlC) has approved this test for insurers to use. Tested positive for HIV Tested positive for Hepatitis I ssted positive for Hepatitis C aiting results of HIV test Awaiting results of Hepatitis B It Awaiting results of Hepatitis C test None of the above If awaiting results of a Hepatitis B or Hepatitis C test. of itself. (A negative HIV or Hepatitis test result will not. for life insurance ovei £500. The Association of British Insurers (AB1) have a policy on genetics and insurance. Please don't assume that we will contact your doctor for confirmation of medical details Client one 1 What is your height (without shoes)? f~ Client two 2 What is your weight (in indoor clothes)? P j . please give the following details: • What wos the higher average I I What was the highei Have you ever been medically advised to reduce your alcohol consumption? (f 'Yes'. A copy of tne AB1 Code of Practice on Genetic Testing is available from us on request or from the ABI website www. or did you. Hepatitis B or C. lifestyle and family medical history Genetic Testing. *g| °* I st lb I I k 9 OR 3 If you smoke cigarettes how many do you. have any insurance).000 in total. If none of these apply. a medical condition including any genetically inherited condition. please tick 'None of the above*. or are having treatment tor. You don't need to tell us about any other genetic test result.PART 2 0 About your health. please give the reason for The iest: . or are you woiting for the results of such a test? Please tick all that apply.uk.abi. Yau must also tell us of any family history of a medical condition as asked for in the relevant question in this application. please give the reason for the test: If awaiting results of a Hepatitis B or Hepatitis C test. Currently. you only need to lell us about any genetic test results concerning Huntington's disease. If you want to tell i:s about a negative genetic test result. The total is for any life insurance application being made now together with any life 'nsurarce you hove already. However.org. please give the following details: What was the r< Have you ever tested positive for HiV. you must tell us if you are experiencing symptoms of.

or any other heart conditi heart abnormalities from birth. Client one 10 Have you ever had any of the conditions listed opposite? a. Hodgkin's disease. for example at blockage.ot intended to be c d. c. for example ecstasy. please give the same details as above. cardiamyopathy A stroke. . for the other condition (s). if you a However. cocaine. please disclose it anyway. ptease complete one of the Medical Questionnaires (Pan* 7) BEFORE continuing with question 11. angina. paralysis. or heroin? B When answering questions 10.Client two tn the lost 5 years have you tested positive or been treated for any sexually? Yes No Yes No ve the following details: Name of the disease How many times have you had this? How long ago was this? Are you fully recovered? years Yes months No j No N 1 Name of the disease 1 How many times have you had this? How long ago w s this? Are you fully recc vered? Do you have any other condition(s) years Yes y months No . narrowing or inflammation? Cancer. e when answering the questions. or any neurological condition. for example motor neurone disease. for the other condition(s). cerebral palsy. that has required refet or a psychiatrist? •"• •" If you have ai iwered 'Yes' to ANY part of question 10. lymphoma. ii arteries in the legs or of the aorta. other than connabis. Parkinson's . transient ischaernic attack (TIA) or Any other condition affecting the arteries. OLP Connect 15/35 . please give the same details as above. 11 and 12.ion disturt epilepsy c Muscular dyslrophy. brain or spinal tut Client two Multiple scle retrobulbor i . Do you have any other condition(s) y to disclose under this heading? | Tes If 'Yes'. in Part 9 (Additional Information) before continuing with this section recreational drugs. Heart attack. in Part 9 (Additional Information) before continuing with this section Q If 'Yes'. there is no need to state the same med any medical condition you have had.. b.

r. or follow-up? c.< " . raised cholesterol. consultation.-. Any numbness.i. or for which you hove not yet been discharged from follow-up? 11 q and llr are only applicable if you have selected Income Protection Benefit or the waiver of premium benefit option: Q If you have answered 'Yes' to ANY part of question 11. deep vein thrombosis'? I d."•'-•. please complete one of the Medical Questionnaires [Part 7) BEFORE continuing with question 12. sciaticc ? —y— Yes No ——L i No . or condition affecting your veins.-. raised blood pressure. for example cataract. advice.1 " -'' -~ f ' !""~r!n. d -> --.: . i T^-: /. not wholly corrected by spectacles or lenses. ''' "" '" ' ' '" "' ' " '' Where examples are snown. or CT scan? 11 p is only applicable to females: which you have needed (urther investigations. OLP Connect 16/35 .-\^Any condition affecting your lungs or breathing.?.-.o-o-.: -. persistent pins and needles or facial pain olher than dental pain? oint o Jb e f ex pie rheumatoid arthritis.-.--. illness or injury not mentioned previously for which: a yOU have been prescribed any treatment? v\hen crtiiwe' ng ^his you ccn igmie nhrc. irregular heart beat. blindness? . for example asfhma. please complete one of the Medical Questionnaires (Part 7} BEFORE continuing with question 13. symptoms.: ~'-i> : : •'-' .'-g '"•-'.n. you have not yet sought medical advice? If you have answered 'Yes' to ANY part of question 12.• ' ' ""'. blood test. tingling.r-u . for example one Disease deafne<o ii i j fi i Lite Ci- int k. ycu haw had or been advi ed tc have any medical or jurgical investigation.-'. for example palpitations. dizziness.r.'-'. •:•: • b. •!-. they ore n o f jntencjgrf pO be a complete list Chest pain.'-. 12 In the lost 12 months have you had any medical condition.-. Any other condition or symptoi which has needed a ECC.•.-o-:i •.'• I'lv <• <.. !^go.txrl. balance problems.c. j Yf t.:. Any blood condition.. Any condition affecting your eyes or vision.-•. tests. [ "1 I Yes h.t 'Jir" c. MRi.11 In the lost 5 years have you had conditions listed opposite? c.-^.

he disorcter(!>' fc f wrrc. where it first occurred in the body. brothers or sisters. If 'Unknown Other'. please answer the 'Unknown' question below. If more than one relative has had a 'Cancer of another site' please state all sites ** If 'Multiple Sclerosis'. please tick 'None of the above' If unknown. We do not need their ages * ff 'Any OTHER disorder which runs in your family for which you are receiving regular follow up or screening' Pleaic give aelCiii cf . please tell us why you can't give details of the medical history of your parents. of Youngest ^°^ affected affected ^^ I follow up or screening*** None of the above Unknown Adopted Unknown Other Unknown No contact Details | Unknown Adopted I Unknown Other Unknown No contact Details " If 'Cancer of another site'. No of Youngest s*cond relatives age V°unges1 affected affected af)^ed Client two Heart attack. please tick ail that apply If 'No'. brothers and sisters. Angina.Client one 13 Have any of your natural parents.yoL> cxe receiving fellow uo a sc'ec-n-ng 14 Doctor's details name Practice/clinic name and address (including postcode) name Practice/clinic name and address (including postcode) I As Client 1 H Telephone number Postcode Telephone number OLP Connect 17/35 Postcode . Angina Stroke or Type 2 Diabetes Cancer of the Breast Cancer of the Ovary Cancer of the Colon [Bowel) Cancer of another site* Cardiomyopathy (primary disorder of the heart muscle] Multiple Sclerosis** Myotonic (Muscular) Dystrophy Polyposis coli (Familial Polycystic Kidney Disease Motor Neurone Disease Huntington's Disease Parkinson's Disease Alzheimer's Disease Any OTHER disorder . that is. Heart attack. Stroke or Type 2 Diabetes Cancer of the Breast Cancel of the Ovary Cancer of the Colon (Bowel) Cancer of another Cardiomyopathy (primary disorder of the heart muscle) Multiple Sclerosis" Myotonic (Muscular) > Dystrophy Polyposis coli (Familial odenoinotous) Polycystic Kidney Motor Neurone Disease Hunfington's Disease Parkinson's Disease Alzheimer's Disease Any OTHER disorder which runs in yout I family for which you are receiving regular | follow up or screening*** None of the above j No. before the age of from any of the conditions listed opposite? (f 'Yes'. please tell us the part of the body affected by the 'primary' cancer. please tell us which family member(s) were/are affected.

how long ago? | Other hospital admission (including overnight stay) years Yes months No months 7 In the last 5 years. in total. ' 3 How long ago did the condition first occur? How often do you have symptoms? Please tick appropriate box . or details of other treatment. you will need to complete o separate Medical Questionnaire for each one. Use this page to give details of the first condition. illness or njury in Part 2. or photocopy th s page. b. have you had surgery or an operation. Medical Questionnaire 1 1 What question number. or are you currently waiting for. c) does this information relate to? Client one Part 2: Question ( ) Client two Part 2: Question ( ) 1 If you have been asked to complete a Medical Quest annaire for more than one condition. any other hospital admission (including an oyernight stay) or referral to a specialist for this condition? months years month.. or any other hospital admission (including an overnight stay) for this condition? years months 4 No.PART 7 fcj Medical Questionnaires This questionnaire only applies if you have been asked in Part 2 to complete a Medical Questionnaire. please state them all 11 Do you have any more medical conditions to disclose as a result of answering 'Yes' to a question in Part 2? g „Tes. please g ve the name of medicine or tablet. . days ago was the most recent occasion? Not apolicable if you have answered '0' to question 7 above 9 Do you expect to have. to g ve the seme details for any further condition(s) illness or injury jf growth or lump. Otherwise. |] yea. please enter '0' Surgery or operat on If -Yes'. please now return to Part 2 and complete the remaining medical questions. p|ease corTlptete the second Medical Q ft 'Yes'. month. 1 more than one treatment. or need for treatment other than your usual medicine or tablets In the last 5 years. when? Other hospital admission (including overnight stay) Yes No Surgery or operat on If 'Yes'. how long ago? Yes years I Ies „ ] years No months No Surgery or opera! on 1 Yes No 1 j H 'Yes'.do not enter anything else in the box How long ago was your iast major attack? This means a sudden increase in the seventy of symptoms. f you are currently off work. please enter '0' years days week. how long ago? Other hospital admission (including overnight stay) If 'Yes'.ymptomsno w Monthly Weekly Yearly Daily No symptoms now Monthly Weekly Yeaily Daily 5 Never hod a major attack Other Current y or at present years months Never had a major attack Other Curren y or at p ye ™ m nthS ° 6 Surgery 01 operation If 'Yes'. how much time off your normal work or daily activities have you had for this weeks f you haven't taken time off. for ex ample physiotherapy. No Other hospital admission (including overnight stay) Yes No 10 Are you currently receiving treatment for this condition? Yes No Yes No If 'Yes'. and question part (for example a. when? Yes I. surgery or an operation. use Medical Questionnaire 2 oppos te for the second and then use the Additional Information section (Part 9 . please complete the second Medical Questionnaire opposite. . please complete the second Medical Questionnaire opposite before returning to Part 2 Questionnaire opposite before returning to Part 2 • • If you do have another medical condition to disclose.

when? Referral to a specialist If 'Yes'. or any an overnight stay) for this condition? ver had Surgery ot operation !' Other hospital admission (including overnight stay) ll'YW. or details of other treatment. how long ago? Yes No monlhs yec rs months yec " 7 In the last 5 years. If more than one treatment. for the other medical condition(s).Medical Questionnaire 2 1 What question number.do not enter anything else in the box I Monthly r^~s mDt attack? This means a sudden increase in the severity of symptoms. please entei If you have had time off. in Part 9 (Additional Information) before returning to Part 2 | (f 'Yes'.photocopy this poge. or are you currently waiting for surgery or an operation. please state them all 11 Do you have any more medical conditions to disclose as a result ot answering 'Yes1 to a question in Part 2? | If 'Yes'. please give the same details as above. when? Other hospital admission (including overnight stay) If 'Yes'.howlonoago? Yes No Surgery or operation Yes No ° Yes No Othet hospital admission (including overnight stay) If 'Yes'. in Part 9 (Additional Information} before returning to Part 2 Please now return to Part 2 and complete the remaining medical question! OLP Connect 27/35 . any other hospital stay) or referral to a specialist for Surgery or operation If 'Yes'. when? Referral lo a specialist II 'Yes'. when? Yes No 10 Are you currently receiving II 'Yes'. for * physiotherapy. to give the same details for any further medical condition(s) Nome of actual medical conditioi illness or injury If growth or lump. or need for treatment other than your usual medicine or tablets In the last 5 years. c) does this information relate to? Client one | Part 2: Question f Use this page to give details of a second condition ind then use the Additional Inforrr o-. please give the name of medicine or tablet. when? Yes No Surgery or operation If 'Yes'. b. and question part (for example a. 3 How long ago did the condition first occur? How often do you have symptoms? •"lease tick cppropr a'e box . in total. please give the same details as above. for the other medical condition(s). have you had surgery or an operation. when? Yes NO E Yes Other hospital admission (including overnight stay) y No N0 | If 'Yes'. how long ago was the most recent occasion? Not cpolicable 'f you hove cnswereo 0 to que^on . coove |f yi 9 Do you expect to have. how daily activities have you had for this If you haven't taken time off.

If so. Brunei House.000.earnings ate defined as your annual pre tax e assessment purposes and can Include your PI Id benefits. General asks you to attend a medical examination. will be given to the Register and m available to other participants. Please refer to your Key Features Document for full Information. • Legal & General will try to rely on the information you provide and you must not assume that they will always clarify that information with your doctor (GP). If you are not sure if any information is relevant. • occupation. • checking details on proposals and claims tor all types of insurance. Legal 8. BTI9 7WZ. You must read carefully the answers you have given to the questions before accepting the fallowing Declaration. please return to the questions and amend your answer in the appropriate place. Approaching fraud prevention agencies: Legal & General will chec my/o details. Genera! Assurance Sociely.r<? of r-. longer receive If nings for PAYE (b) send me/us marketing information about their products and services and products ana services ot companies In the Legal E. less the expenses from running thai business as permitted by the HMRC guidelines.. tnis applies to all). OLP Connect 31/35 .1 PART 10 • • • • • Client Declaration and Consent Please ensure that you have read the notes at the beginning of this form. CF24 OEB. the maximum monthly benefit is £1. s f o r c edit jnts i • managing credit anc • recovering debl. General may ask you to contact your doctor if they are waiting for reports which they have asked for. • country of residence (other than for holidays). Employed . • family history.667 per month. General may sometimes offer revised terms and/or premiums and very occasionally may not be able to offer the benefits requested.earnings are defined qs your share of annual pre tax profit. the terms may differ from those originally quoted. If you have passed a half birthday while the application is being processed.have For all applicants Data Protection Use of personal information: Legal £. Genert I/We understand that Legal & General will us i 'hat ( clain I/We agree to immediately inform Legal & General In writing of any changes to the following answers on the application that occur before the policy starts.. I/We agree that if the policy is to he set up as joint lives. Legal & General may ask for a report from your GP to check medical disclosures. I understand that if.-Hnc c . If ialse or inaccurate inform provided and fraud is identified details will be passed to fraud pre Self employed . with fruud prevention agencies. together information in I'ne event of a claim. it may be necessary to share the application Information with another company which they have authorised. Bangor. For Income Protection Benefit ortly Definition of earnings You should only cover earnings and benefits that you will you are unable to work. AB Clients-.f is mipofiwif mar yo-jrec^anoaccep/ait of Fhefoi'OA'inacaraa'-ODni. If you have given information to Legal & General in the past. • Please remember that all items of information asked for In this application are material facts which are taken into account when assessing acceptance of the application and in calculating the premium. • pastimes. that company will make the arrangements for the examination to fake place.000 of my pre-incapacity earnings and 50% of my pre-incapacity earnings over £30. Legal S General Assurance Society. I/We agree to Legal £. legal 8. about: • medical disclosures. the level of benefit stated in rny policy exceeds this ium I understand that i! I have applied for Housepersans cover. This means your share of the total Income from the business. i' will be own? I/We confirm that I/we have received and read the Key Features for tni product.p and ot third parties whose products and services Legal £.667 per month. The information I/we supply in this application. Access: I/We understand that I/we have the right to ask for a copy of my/our information please write to Legal & General at UKSO Business Standards. Geneial grot. PO Box 274. General will inform you as soon as possible if this is the case. as part of their administrative procedures. I/We understand that failure to do so may result in the contract being declared void and the benefits due under ihe policy not being paid. Providing me/L chtai sharing it with a reinsurer and/or third party administrator. Ry signing this Declaration I/we agree to receive the information as described in (bj obove by post or telephone. If necessary. unless I/we indicate othe'wise by writing with my/our lull caniacl details to Legal 5. at the time of a claim. please disclose it again. See also the paragraph headed 'Sensitive data'. please disclose it anyway. In most instances the payments will be as originally quoted. I/We understand that Insurers share information with each other to prevent fraudulent claims via a Register of Claims and that a list of participants is available on request. If vOu ars ' n. However. General offers to its clients. • If Legal 8. Please also remember that if you do not answer the questions truthfully and accurately it will very likely mean that a claim will be declined and the policy(tes) cancelled. I/We understand the features and risks of Ihe producl and are applied for. Legal 8. • cnecking details of job applicants and employees. Cardiff. The information you give will form the basis of your contract with Legal & General. up to a maximum of £16. General getting relevant information from another this box ii you DO w | 1 Client two I.n-. I understand that my monthly benefit can't be mare than 60% of the first £30.

rheumatism.the results of referrals or tests you are waiting for V. in which case please tick the box below. I/We confirm that I/we accept this Declaration and Consent.s misleading you may ask the doctor to amend it.suicidal thought. Legal &. Hove BN3 7PY.ss/Italians with your GP or any other history ofdegenerative (gradually worsening) diseases. . and the notes section at the beginning of this form. to the process of getting. Before they can ask any doctor that you have consulted to fii! in r: repon they need your permission under the above Acts. or smoking. Kingswooci. Medical Co ent: If Legal £. coi-. or aitempfs at suicide. This • You can ask lo see the reporl before the doctor returns it. or referrals for specialist advice or treatment.tnusculoskeleial disease or injury. hospital admissions. trauma. out if you do noi Legal & General may not be able to go ahead with your application. I/We understand that the full terms and Access to Medical Reports: Notice of your Statutory Rights under the Access to Medical Reports Act 1988. The Droveway. General in the past please disclose it again. Legal &. please medical informati write to: Claims and Underwriting Director. General: • setting premiums at standard rales. It you do this the doctor can see that you require access and keep Ihe report for 21 days so that you can arranae to see it. • any histoiy of disease among your parents or brothers or sisters that you have told your doctor about. If you have given Information to Legal 8. Tadworth.details of any biopsies. Genera! Ass Limited. • You do not need to give your permission. I/W<= have been told that the contract and Wales.details o* any relevant illness. blooa tests. hepatitis 6 or C. General House. assessing or storing medca information. If you have not made arrangements to see the report within this time the doctor will send the Deport to Legal & General. weight if measured in the last two years. Surrey KT20 6EU if I/we your past health . o' . If you do not give any of this information or If you mis-state any information. right. General to gather medical reparis within six months of the start of the policy. General need to obtain a report frym my/our doctor: • I/We do not want to see the reporl before it is sent to Legal & General Client one Q Client two j^j • I/We do want to see the report before it is sent to Legal & General Client one j~| Client two [~~| Please remember that afi ilems of Information requested In this application form are material facts which are taken info account When assessing acceptance of the application and In calculating the premium. City Park. I/We have been told that Legal & Gem policy documentation. the Access to Personal Files and Medical Reports {Northern Ireland] Order 1991. stress . and the isle of Man Arcess to Health Records ana Reports Act 1993. or to support any claim made on tne policy proceeds. I/We authorise those asked to provide medical inf This torm allows Legal &. urinalyses (test on urine). solely for the purposes o! alloivin n collected via this appl'cation) may be psychosis (a mental disorder where you lose contact with reality).any blood pressure readings in the last three years. • The doctor can withhold access to the report if he or she feels 'hat it would The medical reporl your doctor fills in asks about the following: • your current health . please return to the questions and answer in the appropriate place. jhcaTion. • If you choose not to see the report at this stage you may ask the doctor for of the report to the doctor if you ask to see it at a later date • If you think that any part of the report is not correct or . Legal 8. General decide they need to obtain a report have applied for. electrocardiograms (heart tests). It will very likely mean that a claim will be declined and the pottcy(ies) cancelled. .conditions related to drug or alcohol misuse. height. my/our rights under the Access to Medical Reports Act. for example arthritis. . • negative tests for HIV. or chewing tobacco. By signing this Declaration I/we agree to all of the contents. If the doctor refuses to mate the Legal 8. Client one Client two OLP Connect 32/35 . If you are uncertain as to the relevance of any such Information ot If you believe that there U any other Information which may be relevant.• I/We understand that I/we can contact Legal & General at Group Financial Crime.

Otherwise. this is all the information we need. Legal 8. General Assurance Society Limited direct debits from the account detailed in this nstruction subject to the safeguards assured by the Direct Debit Guarantee. Signature and date | Signature and date 1 : I Banks and building societies may not accept direct debit instructions for some types of account . you are entitled to a lull and immediate refund of the amount paid from your bank or building society . f so.PA RT 11 Direct debit instruction This direct debit instruction must be fully completed. General Assurance Society Ltd will notify you five working days in advance of your account being debited or as otherwise agreed. Genera! Assurance Society Ltd or your bank or building society. • If an error is made in the payment of your Direct Debit by Legal 3. details will be passed electronically to my bank or building society. signed and dated before your application can be processed. understand that this instruction may remain with Legal 8. =L —J Q If you want to pay for another product(s) by direct debit from a different bank account(s).| | 4 5 i Reference number Preferred collection date each 7 Instruction to your bank or building society 'lease pay Legal 8. please now cut off the Direct Debit Guarantee below and keep it somewhere safe. confirmation ot the amount and date will be given to you at the time of the request. Written confirmation may be required. Please also notify us.If you receive a refund you are not entitled to.this guarantee shoufd be detached and retained by the payer • This Guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. ^DIRECT FDebit General • If there are any changes to the amount. If you request Legal & General Assurance Society Ltd to collect a payment. OLP Connect 33/35 . you must pay it back when Legal & General Assurance Society Ltd asks you to. General Assurance Society Limited and. • You can cancel a Direct Debit at any time by simply contacting your bank or building society. please complete another direct debit instruction for each bank account(s). Use the Cut off here and keep the Direct Debit Guarantee somewhere safe *• The Direct Debit Guarantee . I t &££A Cieneral f? Instruction to your bank or building society to pay direct debits Originator's Identification Numbers 8 t o J 6 J 1 J 6 J 2 | 9 I j 3 1 4 I 8 [ s l l j f j l U j a ] rt Jp'^J^J 9 9 6 8 4 1 1 1 Name and full postal address of your bank or building society branch To: Address Postcode Bank or Building Society 2 3 Bank account name Bank or building society account number Branch sort code ! 1 |-f | | . date or frequency of your Direct Debit.