Incomeshield Underwritten by Covéa Insurance Plc Income Insurance Data Capture Form
IncomeShield – underwritten by Covéa Insurance plc
Income insurance data capture form
Income insurance protects your ability to meet your financial outgoings if you are unable to work because of an accident, sickness or unemployment.
Please fill in this form and send it back to me so that I can give you aquotefor IncomeShield.
Important: This form isnotan application form. I must discuss the policy features and benefits with you to make sure that it meets your demands and needsbeforesubmitting an application on your behalf.
Applicant detailsTitle and full name
Address
including postcode
Date of birth
/
dd mm yyyy / Gender / Male
Female
Employment status / Employed / Self-employed / Fixed-term contract
Employer name
Employer address
including postcode
Employer industry
Job title
Length of continuous service with this employer / number of months of continuous service
Insurance details
Your gross monthly income / £
The monthly benefit you need(no more than £2,000 or 65% of your gross monthly income, whichever is lower) / £
What type of cover do you need?
Accident, Sickness and
Unemployment (ASU) / Accident and Sickness
only (AS) / Unemployment only (U)
What Qualification period do you need for Unemployment cover(if you have chosen it)?
30-day back-to-day-1 / 60-day excess
30-day excess / 90-day excess / 180-day excess
What Qualification period do you need for Accident and Sickness cover(if you have chosen it)?
30-day back-to-day-1 / 60-day excess
30-day excess / 90-day excess / 180-day excess
How long do you need benefit to be paid for?
12 months / 24 months (only for AS cover)
What date would you like your policy to start? / dd mm yyyy
Important:Cover under this policy cannot be backdated. If you are currently unable to work because of a disability, insurance cover under this policy will only start on the day you go back to work.
If you want to transfer cover from an existing policy, please give the following information
What is the existing type of cover? / ASU AS U Other
(if ‘Other’ please give details at the end of the form)
Name of provider
Start date of existing policy / dd mm yyyy
Amount of monthly benefit / £
Have you made a claim for unemployment within the last 18 months? / Yes / No
If ‘Yes’, please give details
Important:Do not cancel your existing policy until you have received confirmation that your IncomeShield application has been approved.
New borrowers
Are you applying for, or have you taken out, a new credit agreement for a secured or unsecured loan in the 60 days before the start date of this policy? / Yes / No
If ‘Yes’, what date did the agreement start? / dd mm yyyy
Please tick the box that applies to you in each of the following statements
I can confirm I am aged 18 or over but under 64 / Yes / No
I can confirm my work is temporary, casual, seasonal or irregular / Yes / No
I can confirm I am living in the UK / Yes / No
I can confirm I am in paid employment for at least 16 hours a week / Yes / No
I can confirm I have been in full-time employment with my current employer for at least the last 6 consecutive months without a break, immediately before the start date of this policy / Yes / No
I can confirm I have been self employed for at least the last 6 consecutive months without a break, immediately before the start date of this policy / Yes / No
I can confirm I have been a fixed-term contract worker for at least the last 24 consecutive months without a break, immediately before the start date of this policy / Yes / No
I can confirm I understand the pre-existing medical condition exclusions of this policy / Yes / No
I can confirm that I am not currently aware of any circumstances which may result in me making a claim under this policy to become a carer? / Yes / No
I can confirm that in the last 6 months my employer has not formally announced its intention to make cuts to its workforce or made any mandatory reductions in basic salaries or contractual working hours to workforce at my location of work / Yes / No
I confirm that in the last 6 months my employer has not announced that it is going into administration, receivership or liquidation / Yes / No
I can confirm in the last 6 months I have not received any formal or informal notification that my own job might be at risk / Yes / No
I confirm that I have not been registered as unemployed at any time in the 12 months immediately prior to the start date of this policy / Yes / No
If you have answered ‘No’ to any of the above questions, please give details below:
Your duty in relation to this form
In arranging your insurance we and the Insurer will ask a number of questions which you are required to answer. Please take reasonable care to answer all the questions honestly, to the best of your knowledge and provide full answers and relevant details. If you do not answer the questions honestly or to the best of your knowledge then your policy may be cancelled or your claim rejected or not fully paid.
Once you have filled in this form, please send it back to me so I can produce an insurance quotation for you, based on your needs.
Data protection: Please contact me if you would like more information about how we handle and store your personal data.
There are other providers of Short Term Income Protection and other products designed to protect you against loss of income. For impartial information about insurance, please visit the website at:
A typical monthly cost for Paymentshield Short Term Income Protection is £5.18 for every £100 of monthly benefit you would get. The monthly cost includes Insurance Premium Tax (IPT) at the present rate of 9.5%. The cost is based on a customer aged 31-35 who has taken out a new credit agreement taking out our full accident, sickness and unemployment option with 30-day back-to-day-one cover, 12 months' benefit, no deferred premium payment period and protecting an income of £755 a month.
Client Name
Date / dd mm yyyy