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DATA CAPTURE FORM

This form can be used to capture the information you’ll need from your client to apply for a Protection policy. This is not an application form. We only accept business submitted online at guardian1821.co.uk. For more than one person, you’ll need to capture details of the second life on a separate form.

If your client answers ‘yes’ to any of the questions in this data capture form, you’re likely to be asked to give us further information in the online journey.

Please make sure your client is aware that you’ll need to contact them for more information and please check that you have their permission to give us their data. You can refer them to our privacy policy on our website.

We’ll give your client a copy of the answers you provide online, in their Welcome pack when the policy goes in force.

Please take care when answering the questions to make sure they’re accurate, true and complete. If not, you risk your client’s cover being cancelled or when we assess a claim you risk us paying a reduced amount or nothing at all.

Your client’s don’t need to tell us the results of any genetic test, except for a positive test for Huntington’s disease if they’re applying for insurance of more than £500,000.

We may need to ask your doctor for information to support or check the answers you gave us in your application. If we do, we’ll need your consent under the Access to Medical Reports Act (AMRA) 1988. By continuing this application, you’re agreeing to sign the AMRA form if asked to do so. If you don’t sign it, we may cancel your policy if we’ve already offered you cover. You can still apply to other companies for insurance.


DATA CAPTURE FORM

CLIENT DETAILS

Who needs cover:

Gender: Male Female

Date of birth:

What best describes your Used in the last 12 monthsuse of tobacco1 or nicotine replacement products2 None in the last 12 months

None in the last 5 years

What is your height without shoes?

or

What is your weight in normal indoor clothing?

or

Waist size? or or

Postcode:

Job:

Annual salary/income: £

1 Tobacco products include cigarettes, cigars and pipes. 2 Nicotine replacement products include patches, e-cigarettes, chewing gum, lozenges, inhalers and sprays.


DATA CAPTURE FORM

CORE COVERS

Life Protection

Cover type: Level Increasing Decreasing Family income

Amount of cover/ Monthly benefit amount: £

Term: years or until age:

Critical Illness Protection

Cover type: Level Increasing Decreasing Family income

Amount of cover/ Monthly benefit amount: £


Combined Life and Critical Illness Protection

Cover type: Level Increasing Decreasing

Amount of cover: £


OPTIONAL COVERS – CAN ONLY BE TAKEN OUT WITH A CORE COVER

Children’s Critical Illness Protection

Amount of cover: £


DATA CAPTURE FORM

CLIENT INFORMATION

Contact details Email:

Phone number:

Address including postcode:

Existing coverIf your client already has cover in place that you intend to cancel, you don’t need to include it in this section.

If the amount applied for in this application, when added to concurrent applications and any existing policies, exceeds the limits shown below, please answer yes.

£1,000,000 life cover Yes No Please also include the amount of life cover from any combined life and critical illness policy.

£500,000 critical illness cover Yes No Please also include the amount of critical illness cover from any combined life and critical illness policy.

Is any of the cover associated Yes No with a new or existing mortgage?


DATA CAPTURE FORM

Children’s detailsAdd the details for the children’s critical illness cover. We need all children’s names and dates of birth so we can let your client know when their children are no longer covered.

You can also cover an unborn child: enter TBC and TBC in the name fields along with today’s date instead of date of birth. And once the child is born, tell us their name and date of birth and we’ll update our policy records.

Child’s name:

Date of birth:

Child’s name:

Date of birth:

Child’s name:

Date of birth:

Child’s name:

Date of birth:

YOUR LIFESTYLE

Tobacco or nicotine replacement productsHave you given up smoking or Yes No do you only use nicotine replacement products1?

If No, how many do you smoke a day on average? (If you use tobacco occasionally or are a social smoker who does not smoke every day please enter 0).

Cigarettes, small cigars or cigarillos Number per day

Cigars Number per day

Pipes Number per day

1 Nicotine replacement products include patches, e-cigarettes, chewing gum, lozenges, inhalers and sprays.


DATA CAPTURE FORM

Alcohol and drugs How much alcohol do you drink Pints of beer, lager or ciderin a typical week?

Wine (standard 175ml glass)

Wine (large 250ml glass)

Spirits (25ml pub measure)

In the last 5 years, other than Yes No cannabis have you used recreational drugs — for example cocaine, ecstasy, heroin, methadone or anabolic steroids that were not prescribed by a doctor?

If you answered Yes please provide full details here, including details of drug usage and last date of use:

Have you ever received advice, Yes No treatment or counselling for the use of alcohol, drugs or non-prescribed medication or had a blood test as a result of your drinking?

If you answered Yes please provide full details here:


DATA CAPTURE FORM

Your jobWhat is your job?

Do you work less than 16 hours Yes No a week?

Are you a member of the armed Yes No forces, territorial army or a reservist?

If Yes:

Are you under orders for active Yes No service duty?

Do you fly as pilot or aircrew in Yes No the course of your duties?

Are you a full time member Yes No of the military?

Are you a member of the Yes No Territorial Army or Reservist?

Travel and residenceHave you lived in the UK and Yes No been registered with a UK doctor for the last 2 years?

Have you or do you visit any Yes No doctor outside the UK for medical treatment, investigations or advice?

Have you lived in Africa, Thailand, Yes No Russia, Ukraine or the Caribbean for more than 3 months during the last 5 years?

If you answered Yes, HIV and Hepatitis tests may be required. Without these we will not be able to consider the application.


DATA CAPTURE FORM

In the next 2 years are you Yes No planning to travel, live or work outside of the European Union (EU), Isle of Man, Channel Islands, North America, Australia or New Zealand?

(You don’t need to tell us about any holiday you are taking that is less than 30 days in a year)

If you answered Yes please provide full details here (Name of country and duration of stay):

Sport activities Do you currently, or do you intend to, participate in any of the following activities? Please choose all that apply. You can ignore one off events whilst on holiday or for charity.

Mountaineering Yes No

Scuba or deep sea diving Yes No

Long distance sailing Yes No

Flying (other than as a fare Yes No paying passenger)

Motor sports Yes No

Extreme sports (such as, but not Yes No limited to, bungee or base jumping, canyoning, caving/potholing, white water rafting)

Professional or semi-professional Yes No sport (including, but not limited to, rugby league, rugby union, football)

If you answered Yes to any of these questions then please provide full details here:


DATA CAPTURE FORM

2 female applicants only 3 male applicants only

Any other disorder that runs in Yes No/Don’t know your family that: you have been tested for or are under surveillance for or for which you are receiving regular follow-ups?

If you answered Yes to any of these questions then please provide full details here:

FAMILY HISTORY

Have any of your natural parents, brothers or sisters been diagnosed with or died from any of the following illnesses before the age of 60.

If you do not know all your family history please tell us what you do know. For any question you can’t answer because you are adopted, no longer in touch or do not know please select ‘No/Don’t know’:

Heart attack, angina or stroke Yes No/Don’t know ( you do not need to tell us about a family history of TIA)?

Cancer of the breast2, ovary2 Yes No/Don’t know or colon3?

Diabetes? Yes No/Don’t know

Multiple Sclerosis? Yes No/Don’t know

Huntington’s Disease? Yes No/Don’t know


DATA CAPTURE FORM

YOUR HEALTH – IN THE LAST 5 YEARS

Apart from what you have already told us, in the last 5 years have you had any of the following:

Raised blood pressure or Yes No cholesterol, chest pain, or irregular heart beat?

Epilepsy, multiple sclerosis, Yes No muscular dystrophy, cerebral palsy, parkinson’s disease, alzheimer’s disease or dementia?

Abnormality or disease of the Yes No kidneys, bladder, liver or pancreas?

Anaemia, haemophilia, or Yes No other blood disorder?

YOUR HEALTH

Your previous medical history is an important indicator of your health. Please answer these questions honestly and accurately as your answers may affect any claim. Have you ever had any of the following:

Cancer, Hodgkin’s lymphoma, Yes No Non-Hodgkin’s lymphoma or leukaemia?

Heart attack, heart disorder, Yes No angina, heart valve or structural abnormalities or cardiomyopathy?

Stroke or Transient Ischaemic Yes No Attack (TIA), brain injury, brain haemorrhage, any form of bleeding into your brain or any surgery to your brain?

Diabetes or sugar in the urine? Yes No

Any psychiatric or mental disorder Yes No (including eating disorder or suicide attempt) that has required an overnight stay in hospital or referral to a psychiatrist?

A positive test for HIV or Yes No Hepatitis B or C or are you waiting for the results of such a test?

A negative HIV test won’t by itself have any affect on your acceptance terms for insurance.


DATA CAPTURE FORM

Paralysis, seizures, loss of balance, Yes No blurred or double vision, loss of feeling, numbness, persistent tingling or pins and needles serious enough to have been reported to your doctor?

Ulcerative Colitis, Crohn’s disease, Yes No bleeding from the bowel or any other disorder of the bowel, stomach or oesophagus that lasted more than 5 days or has resulted in any hospital investigation?

YOUR HEALTH – IN THE LAST 3 YEARS

Apart from what you have already told us, in the last 3 years have you had any of the following:

Asthma, bronchitis or other Yes No respiratory disorder?

Anxiety, stress, depression, Yes No insomnia, chronic fatigue or eating disorders or any mental health problem that has:

Led you to consult a health professional (for example nurse, doctor, psychologist)?

Prevented you from working or carrying out your normal daily activities for more than 5 continuous days?

Any lump, cyst, growth of any Yes No kind (including skin growth)?

Had back, neck, joint or muscular Yes No condition requiring you to take any type of medication or to consult a health professional, for example a nurse, doctor, physiotherapist or chiropractor?

(This includes sciatica, slipped disc, muscular back pain or whiplash and/or conditions or pain affecting your hips, shoulders, knees, ankles or wrists.)

An abnormal cervical smear, or Yes No abnormal mammogram or other gynaecological condition that has needed more than one consultation4?4 female applicants only


DATA CAPTURE FORM

Taken (or are you currently taking) Yes No any form of medication or treatment lasting more than 1 month or attended hospital or clinic for tests or investigations?

YOUR HEALTH – IN THE LAST 3 MONTHS

In the last 3 months have you noticed or become aware of:

A lump or swelling, firmness Yes No or hardening, or a mole that’s changed in appearance or required monitoring?

Any other breast, testicular Yes No or skin changes?

Any unexplained bleeding Yes No or weight loss?

A cough that has lasted for Yes No more than 3 weeks?

YOUR HEALTH – IN THE LAST MONTH

In the last month have you:

Tested positive for Yes No Coronavirus illness (Covid-19)?

Been personally advised to Yes No self-isolate by a medical professional or the NHS 111 but have not been diagnosed with Coronavirus illness (Covid-19)? (If you’re working from home or following general advice to practice social distancing, you should not consider yourself as self-isolating).

Had, or do you currently have Yes No a new, continuous cough and/or high temperature?

Had direct contact with someone Yes No who’s been confirmed or suspected to have Coronavirus illness (Covid-19)?


DATA CAPTURE FORM

YOUR HEALTH – AT THE MOMENT

Apart from any medical conditions you’ve already told us about, are you currently:

Intending to seek any medical Yes No advice or under regular follow up?

Currently undergoing or awaiting Yes No medical investigations or tests?

Waiting for any form Yes No of treatment to start?

Experiencing any new symptoms Yes No for which you are planning to see a medical professional or your GP?

If your client answers ‘yes’ to any of the questions in this data capture form, you’re likely to be asked to give us further information in the online journey.

You may want to let your client know that you’ll be in touch for more information.

SET UP

Bank detailsName on bank account:

Account number:

Sort code: – –

Payment detailsPreferred collection date: of the month

Start date of the policy:


DATA CAPTURE FORM

Payout Planner – nominate death beneficiariesGiving us beneficiary details means we can pay death benefits quickly after a claim. Your client’s cover summary will include the beneficiaries they nominate today. They can update them anytime by calling us. You won’t be able to choose Payout Planner after you’ve completed this screen.You can set up a Trust, which overrides Payout Planner, at any time in the future.

Life ProtectionPlease provide beneficiaries details

First name: Last name: Date of birth (optional): Percentage:

By ticking this box, I confirm my client doesn’t want to use Payout Planner for Life Protection. They understand without Payout Planner, a trust or any other legal alternative, their payout could be delayed.

Combined Life and Critical Illness Protection Please provide beneficiaries details for the life element of this cover, ( you can’t nominate beneficiaries for the critical illness element of this cover).

First name: Last name: Date of birth (optional): Percentage:

By ticking this box, I confirm my client doesn’t want to use Payout Planner for the life element of Combined Life and Critical Illness Protection. They understand without Payout Planner, a trust or any other legal alternative, their payout could be delayed.

DATA CAPTURE FORM

FOR ADVISER USE ONLY

Adviser name:

% indemnity commission:

% of commission sacrificed:

MORE INFORMATION

CFS

A 0

098

042

0

Guardian Financial Services Limited is an appointed representative of Scottish Friendly Assurance Society Limited. All products are provided by Scottish Friendly.

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Guardian Financial Services Limited is an appointed representative of Scottish Friendly Assurance Society Limited which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation Authority. Registered office: Scottish Friendly House, 16 Blythswood Square, Glasgow G2 4HJ. Registration number 110002. Guardian Financial Services Limited is registered in England and Wales under number 11115769. Registered office: 11 Strand, London WC2N 5HR.

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