Application Form - Aviva
Global TermApplicationformFA 2005 FPI GT AppForm CS5.5.indd 15/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMGeneral InformationIf you have already applied for cover with us, please state your policy number, if known.Part 1: Financial adviser details – to be completed by the adviserCompany nameCompany addressAgency numberContact details for acknowledgement/queries on the application.Adviser nameTelephone numberFax numberEmail addressWhere the application is for cover(s) other than Life Cover, I have passed the relevant health insurance module conducted by theSingapore College of Insurance.1 I have submitted the equivalent of sections 11, 12 and 13 of the Life Insurance Advisory Form (Life Insurance Association, Singapore).2 Choose either of the following:a) The client(s) and I have completed the needs analysis according to the Life Insurance Association’s Life Insurance Advisory Form.b) The client(s) have opted not to carry out the needs analysis according to the Life Insurance Association’s Life Insurance Advisory Form.Country where advice is givenCountry where application is signedSignature (to be signed by the adviser)3 Client(s) must endorse if option 2(b) above has been selected:I/We have opted not to carry out the complete needs analysis according to the Life Insurance Association’s Life InsuranceAdvisory Form with my/our Adviser.If a material fact is not disclosed in this application, any policy issued may not be valid. If you are in doubt as to whether a fact ismaterial, you are advised to disclose it. This includes any information that you may have provided to the financial adviser but wasnot included in the application. Please check to ensure that you are fully satisfied with the information declared in this application.First (or only) life assured/applicantSecond life assured/applicantSignature(s)Date (DD/MM/YYYY)Failure to provide all relevant information and documentation will result in a delay to the application being processed. Further informationmay be required during the validation process (i.e. questions arising from the information provided).Please note that even if the premium has been received and banked, the policy will not be issued until all documentation hasbeen received and validated.Please complete this form in black ink. If you make any mistakes while completing this application form, please cross out the error andwrite the new information clearly. The life assured must initial any corrections for questions they have answered. Do not use correctionfluid or other ways of deleting incorrect information.Checklist – please complete all sectionsParts 2 – 10Fully completedPages 31 – 35Part 12Personal Data Protection Act 2012(PDPA) Personal Data Protection Consent DeclarationPart 13Declarations signedPayment detailsEnclosed certified copies of client’s identityEnclosed certified copies of client’s utility bill (or suitable alternative) to verify residential address2Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 2Global Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMWARNING: PURSUANT TO SECTION 25(5) OF THE INSURANCE ACT OF SINGAPORE (CAP.142), YOU ARE TO DISCLOSEIN THIS APPLICATION FORM, FULLY AND FAITHFULLY, ALL THE FACTS WHICH YOU KNOW OR OUGHT TO KNOW,OTHERWISE THE POLICY ISSUED HEREUNDER, MAY BE VOID.It is most important that you read this part before completing the application form. This application form should be read in conjunctionwith the following documents, which set out the terms and conditions of the contract: the Global Term product summary Your Guide to Health Insurance Infographic: Evaluating my health insurance coverage(To be read together with Your Guide to Health Insurance) Your Guide to Life Insurance the Global Term policy conditions Your personal benefit illustration.DeclarationPlease tick all appropriate boxes and sign where indicated before proceeding.‘Accredited’ and ‘Non-Accredited’ InvestorsThe applicant(s) must state whether or not they are an ‘Accredited’ Investor as defined under Section 4A of the Securities and Futures Act(Cap.289) (‘SFA’). Under this Act, an ‘Accredited’ investor means an individual:a) whose net personal assets exceed in value SGD 2 million (or its equivalent in a foreign currency) or such other amount as theAuthority may prescribe in place of the first amount; orb) whose income in the preceding 12 months is not less than SGD 300,000 (or its equivalent in a foreign currency) or such other amountas the Authority may prescribe in place of the first amount.There are also requirements for corporate investors. Please refer to the SFA for more details.This definition may be changed by the Monetary Authority of Singapore from time to time.First (or only) applicantSecond applicantAccredited InvestorNon-Accredited InvestorIf a material fact is not disclosed in this application, any policy issued may not be valid. If you are in doubt as to whether a fact ismaterial, you are advised to disclose it. This includes any information that you may have provided to the financial adviser but was notincluded in the application. Please check to ensure that you are fully satisfied with the information declared in this application.Signature(s)Date (DD/MM/YYYY)Part 1: Replacement of life policiesa) Does the policyholder have any existinglife insurance policy(ies) with FriendsProvident International or any otherfinancial institutions?First (or only) life assuredSecond life assuredYesYesNoNoIf Yes, please complete the following table.First (or only) life assuredName of companyCountry of insuranceType of policySum assuredYear issued CurrencyTerm3FA 2005 FPI GT AppForm CS5.5.indd 35/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 1: Replacement of life policies (continued)Second life assuredName of companyCountry of insuranceb) Is this application intended to replaceany policies of any other financialinstitutions including Friends ProvidentInternational?Type of policySum assuredYear issued CurrencyFirst (or only) life assuredSecond life assuredYesYesNoTermNoIf Yes, please indicate the policy numbers below.Relevant informationWarning: It is usually disadvantageous to replace an existing life insurance policy with a new one. Some of the disadvantages are:i) You may not be insurable on standard terms.ii) You may have to pay a higher premium in view of a higher age.iii) This may result in losing the financial benefits accumulated over the years.In your own interest, we would advise that you consult your present insurer before making a financial decision. You can then makea careful comparison.1 Disclosure of all relevant information Help us to assess your application by giving us all the information we ask for. All the questions we ask are relevant andimportant. You must answer them accurately and completely to the best of your knowledge. If you do not, we will have thelegal right to cancel any policy issued as a result of your application and to not pay any claim. If anything about your health or circumstances changes after you have completed this application and before we assumerisk for the cover applied for, you must let us know immediately. We need to know of any changes which would have resultedin different replies to questions asked either: on or resulting from the application form or other questionnaire; or by any doctor ornurse acting on our behalf. To inform us of any such change, please telephone our Singapore office on (00) 65 6320 1088;email: singapore.enquiries@fpiom.comChanges would include having, or expecting to have, doctor, hospital or clinic consultations, treatment as an in-patient or out-patientor a blood test for any reason. We also need to know immediately if you change your occupation, country of residence or intendedresidence, or take up any hazardous sports or pastimes before cover starts. If we are advised of any changes, we will confirm in writing whether or not any terms quoted will still apply.2 Terms and conditions You should seek guidance from your usual financial adviser as to the suitability of the policy to your own particular circumstances.Before completing this application, you should read our standard terms and conditions. You are entitled to ask for a copy of yourapplication form at any time.3 Medical evidenceFriends Provident International will only pay for medical information which it has specifically requested.4Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 4Global Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPlease write in black ink and use BLOCK CAPITALS.Policy detailsPart 2: Lives assured detailsThe life (lives) assured is/are the person(s) on whose life (lives) the policy will be written.First (or only) life assuredSecond life assured1 TitleMrMrsMissMsOtherMrMrsMissMsOther2 Surname (as shown on NRIC or passport)3 First name(s) (as shown on NRIC orpassport)4 AliasesYesNoYesNoIf Yes, please specify5 Unique identification number (NRIC orpassport)6 Permanent residency visa number(if applicable) or ID number (if applicable)7 Marital edDivorcedOtherWidowed8 Date of birth (DD/MM/YYYY)9 Current residential address (includingstreet name, town and area code, ifknown)10 How long have you lived at this address?11 Correspondence address (if differentto residential address)12 Relationship or nature of interestbetween the two lives assured(if applicable)You will receive your policy documents and all correspondence relating to your plan, unless you indicate otherwise below.Copies will also be sent to your financial adviser.Alternatively, please tick here if you would prefer us to send your policy documents and all correspondence relatingto your policy to your financial adviser only.I/We acknowledge that the above indication of preference does not prohibit direct responses to enquiries from yourselvesor my/our financial adviser.13 Please list all contact details below.Contact detailsHome telephone number (mandatory)Office telephone number (mandatory)Mobile number (mandatory)Email address (mandatory)5FA 2005 FPI GT AppForm CS5.5.indd 55/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 2: Lives assured details (continued)Medical details14 Do you have a regular doctor ormedical practitioner?Please note that we might not contactyour doctor. Even if we do, you muststill disclose all facts when completingthis application.YesNoYesNoIf Yes, provide full name and address of your regular doctor or medical practice/centre,including fax number.Doctor’s or medical practitioner’sfull nameDoctor’s or medical practitioner’saddressMedical practice/centre nameMedical practice/centre fax numberHow long has your regular doctorknown you?YearsMonthsYearsMonthsWhen did you last attend yourregular doctor? (DD/MM/YYYY)What was the reason for your last visit?Part 3: OccupationFirst (or only) life assuredSecond life assured1 What is your occupation? (If you havemore than one occupation, pleaseprovide full details of each one.)2 What is the name of your employer?3 What is the address of your employer?4 What is the nature of your employer’sbusiness? (e.g. Financial Services)5 Please give details if you workunderground, underwater, at heights over3 metres, offshore or any other hazardousaspects of your occupation.6 Please give percentage of working timespent at heights, if applicable.7 Please give average and maximumheights worked (in metres).6Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 6%Average%MaximumAverageMaximumGlobal Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 4: Plan detailsPlease indicate required currency:SGDUSDPlease indicate premium payable:MonthlyHKDGBPEURAnnuallyThe minimum amount of cover for any individual policy is SGD 845,000, USD 500,000, HKD 4,000,000, GBP 282,000, EUR 437,500.1 How much Life Cover do you require?A policy for first life assured onlyA policy for second life assured onlyA policy for joint lives assuredAmount of coverAmount of coverAmount of coverAmount ofpremiumorTermAmount ofpremiumyearsTotal and PermanentDisability BenefitTick box if you areplacing your policyunder trust prior topolicy productionorTermAmount ofpremiumyearsTotal and PermanentDisability BenefitTick box if you areplacing your policyunder trust prior topolicy productionorTermyearsTotal and PermanentDisability BenefitFirst life assuredSecond life assuredBoth livesTick box if you areplacing your policyunder trust prior topolicy production(Guaranteed premiums. Maximum to age 80. However, Total and Permanent Disability Benefit, if selected, will cease on thelife assured’s 65th birthday.)2 How much Life or Earlier Critical Illness Cover do you require?A policy for first life assured onlyA policy for second life assured onlyA policy for joint lives assuredAmount of coverAmount of coverAmount of coverAmount ofpremiumorTermAmount ofpremiumyearsTick box if you areplacing your policyunder trust prior topolicy productionorTermTick box if you areplacing your policyunder trust prior topolicy productionAmount ofpremiumyearsorTermyearsTick box if you areplacing your policyunder trust prior topolicy production(Reviewable premiums, maximum to age 80.)7FA 2005 FPI GT AppForm CS5.5.indd 75/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 4: Plan details (continued)3 How much Critical Illness Cover do you require?A policy for first life assured onlyA policy for second life assured onlyA policy for joint lives assuredAmount of coverAmount of coverAmount of coverAmount ofpremiumorTermAmount ofpremiumyearsorAmount ofpremiumTermTick box if you areplacing your policyunder trust prior topolicy productionyearsorTermTick box if you areplacing your policyunder trust prior topolicy productionyearsTick box if you areplacing your policyunder trust prior topolicy production(Reviewable premiums, maximum to age 80.)Start dateShould anything about your health or other circumstances change before Friends Provident International has assumed risk forthe policy you have applied for, you must tell us immediately. We will then confirm whether any terms we have quoted will remainavailable. Failure to notify us of any such change may result in the policy becoming void and the benefits not becoming payable.We will start your policy immediately if your application is accepted on our normal terms, unless you state a date below on which youwould like it to start or have instructed us otherwise.If your application is not accepted on our normal terms, the policy will not start until we receive written notification of your acceptanceof any revised terms Friends Provident International offers, and your instructions to go on risk.In any event, risk cannot be assumed under the Policy before your application is accepted by Friends Provident International on normalterms, or Friends Provident International receives your acceptance of any revised terms.We also need to have received your first premium payment or a completed Banker’s standing order, Interbank giro or Credit card authority.Effective date (DD/MM/YYYY)Part 5: Residential and travel detailsFirst (or only) life assuredSecond life s1 What are your nationalities?Please list all.2 Country of birth3 Town of birth4 What is your current country of residence?5 What is the legal basis of your stay inthe current country of residence(e.g. permanent resident visa)?6 How long have you lived in your currentcountry of residence?How long do you intend to stay in yourcurrent country of residence?If you intend to change your country ofresidence, please provide full details.8Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 8Global Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 5: Residential and travel details (continued)First (or only) life assuredSecond life assuredYesNoYesNoYesNoYesNo7 In which countries have you lived andfor how long?8 Has your occupation involved traveloutside your current country ofresidence in the last two years?If Yes, please give details includingspecific countries visited, dates andduration of stay.9 Do you expect your occupation toinvolve travel outside your currentcountry of residence in the future?If Yes, please give details includingspecific countries visited, dates andduration of stay.Part 6: Recreation detailsTo qualify for ‘non-smoker’ status rates, you must not have used any form of tobacco or nicotine products within the last 12 months.1 Have you ever smoked or usedany form of tobacco (for example,cigarettes, cigars, pipe tobacco, shishapipe) or nicotine product (for example,nicotine patches, nicotine gum) in thelast 12 months?First (or only) life assuredSecond life assuredYesYesNoNo(Random tests may be carried out to verify non-smoker status)If Yes, what form, e.g. cigarettes?How many, e.g. 20 per day?per dayper dayper dayper dayIf you have given up, when did youlast use tobacco? (DD/MM/YYYY)What form, e.g. cigarettes?How many, e.g. 20 per day?9FA 2005 FPI GT AppForm CS5.5.indd 95/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 6: Recreation details (continued)2 Do you drink alcohol?First (or only) life assuredSecond life assuredYesYesIf Yes, how many units per week?Nounits per weekNounits per week(1 unit a single measure of spirits or 1 glass of wine (125ml) or 1 2 pint of beer (250ml)Have you ever been advised by adoctor or any other medical practitionerto reduce or stop your alcoholconsumption on medical grounds orhave you ever taken part in counselling,therapy or a programme with the aimof reducing or stopping your alcoholconsumption? If Yes, please give details.3 In the last 7 years have you taken anynon-prescription drugs (for example,LSD, ecstasy, cocaine, heroin, cannabis,anabolic steroids, etc.)? If Yes, pleasegive details.4 Do you take part in any hazardous sportor pastime or do you intend to start?(Mountaineering, motor sport, sub-aquadiving and private flying are examplesbut you should include any activity thatis hazardous. You do not need to includesports such as horse riding, skiing,football, rugby, hockey, cricket or racquetsports.) If Yes, please give details.10Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 10YesNoYesNoYesNoYesNoYesNoYesNoGlobal Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 7: Financial details1 Please give your annual earned income.First (or only) life assuredSecond life assuredCurrency, e.g. SGDCurrency, e.g. SGDAmountAmount2 Please provide details of any existing life, disability or critical illness insurance on your life. Please continue at the end of thisdocument, if necessary.First (or only) life assureda Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredCurrencyAmountStart date and term ason for policyb Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredCurrencyAmountStart date and term (DD/MM/YYYY)Reason for policyc Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredCurrencyAmountStart date and term (DD/MM/YYYY)Reason for policyd Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredStart date and term (DD/MM/YYYY)CurrencyAmountReason for policy11FA 2005 FPI GT AppForm CS5.5.indd 115/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 7: Financial details (continued)Second life assureda Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredCurrencyAmountStart date and term ason for policyb Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredCurrencyAmountStart date and term (DD/MM/YYYY)Reason for policyc Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredCurrencyAmountStart date and term (DD/MM/YYYY)Reason for policyd Type of cover (e.g. Life, Critical Illness, etc.)Country of insuranceName of insurerSum assuredStart date and term (DD/MM/YYYY)CurrencyAmountReason for policy12Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 12Global Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 7: Financial details (continued)Are any of these policies to be cancelledonce this application is in force?First (or only) life assuredSecond life assuredYesYesNoNoIf Yes, please give company name.Please give policy reference.We may request evidence of earned income due to the level of cover in existence. Examples of evidence includes latest tax statement, statementfrom employer and last three month’s payslip.3 Apart from the above, have you appliedto any other company for life, disabilityor critical illness insurance in the last12 months or are you about to do so?YesNoYesNoIf Yes, please give company name.Please give date of application.(DD/MM/YYYY)Sum assuredCurrencyAmountCurrencyAmountPlease give reason for policies.Is only one application to proceed?4 Have you ever applied for life assurance,insurance against ‘critical illness’ or incomeprotection/disability insurance and beenturned down or asked to pay a higherpremium or have other special terms beenimposed?YesNoYesNoYesNoYesNoIf Yes, please give company name.Please give date of application.(DD/MM/YYYY)Sum assuredCurrencyAmountCurrencyAmountPlease give reason for adverse decision.13FA 2005 FPI GT AppForm CS5.5.indd 135/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 7: Financial details (continued)5 Please complete one section from either a) personal cover or b) business protection. Please complete each appropriate section.a)Personal coverPersonal protection (i.e. family cover) Please tick if required.First (or only) life assuredSecond life assuredPlease tell us the relationship ofany dependants.Please tell us the ages ofany dependants.YearsYearsYearsYearsPlease contact Friends Provident International to discuss requirements for sums assured greater than USD 4m orequivalent currency.Personal loan protection (including mortgage) Please tick if required.What is the reason for the loan?If it is for a mortgage, please tellus whether it is for your own mainresidence or investment.Name of lenderb)Amount and duration of loanAmountIs the loan conditional on issueof this policy?YesDurationMonthsNoBusiness protectionBusiness protection Please tick if required.This includes keyman protection, partnership or shareholder protection or a loan taken out by or on behalf of abusiness.What is the reason for the coverand how was this sum assuredderived?14Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 14Global Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 8: Family historyBefore the age of 60, have any of your natural parents, brothers or sisters had, or died from, heart disease, stroke, diabetes, cancer,Huntington’s disease, polycystic kidney disease, polyposis of the colon, multiple sclerosis, Alzheimer’s disease, Parkinson’s disease,motor neurone disease, muscular dystrophy or any hereditary disorder not already listed above?First (or only) life assuredYesNoSecond life assuredYesNoIf Yes, please complete the relevant section(s) below with details of any of the conditions listed above. Please state the age at onset ofthe medical condition and in the case of cancer, which part of the body was first affected.First (or only) life assuredRelationship to you of person affectedMedical conditionAge at onsetof conditionSecond life assured15FA 2005 FPI GT AppForm CS5.5.indd 155/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 9: Health questionsYou are not required to complete this section if a routine medical examination is required. Please go direct to Part 10.All the questions we ask are relevant and important. You must answer them accurately and completely to the bestof your knowledge. If you do not, we will have the legal right to cancel any protection cover issued as a result of yourapplication and not to pay any claim.If the answer to any question is ‘Yes’, please give full details disclosing all facts as they can influence the assessmentand acceptance of the application.First (or only) life assuredSecond life assured1 What is your height?ftinor cmftinor cmWhat is your weight?stlbsor kgstlbsor kgYesNoYesNoHave you lost more than 1 stone or 6kilograms in the last 6 months?If Yes, please provide details.2 Do you currently have or have you ever had any of the following:16a) Cancer, leukaemia, Hodgkin’sdisease, lymphoma or anytumour?YesNoYesNob) Any lump, cyst or growth thathas appeared or grown in size,or a mole or freckle that hasbled, caused pain or changed inappearance?YesNoYesNoc) Heart disease, angina, a heartattack, heart abnormality ordefect, heart valve disorder oran irregular heart beat, chestdiscomfort or pain, disease of orany other disorders of the heartor blood vessels?YesNoYesNod) Raised blood pressure or raisedcholesterol for which treatment,further readings or a change indiet were advised?YesNoYesNoe) A stroke, mini stroke, transientischaemic attack (TIA) or a brainor subarachnoid haemorrhage?YesNoYesNof) Multiple sclerosis, Parkinson’sdisease, Alzheimer’s disease,paralysis or paraplegia?YesNoYesNog) Visual disturbance, blurred ordouble vision, optic or retrobulbarneuritis?YesNoYesNoFriends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 16Global Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 9: Health questions (continued)First (or only) life assuredSecond life assuredh) Any impairment of vision, speechor hearing or any disorder of theeyes or ears? (You may ignoresight problems corrected byglasses or contact lenses butyou must tell us about all hearingproblems, even if corrected byhearing aid(s).)YesNoYesNoi) Tingling, pins and needles,numbness, weakness of limb, atremor or any loss of feeling, balanceor coordination, for which youconsulted a doctor or hospital?YesNoYesNoj) Recurrent headache for which youhave consulted a doctor or anyepilepsy, seizure, fit or blackout?YesNoYesNok) Diabetes, thyroid disorders or anyother endocrine disorder?YesNoYesNol) Have you ever tested positive forHIV, hepatitis B or C or are youawaiting the results of such a test?(If the result was negative, the factof having an HIV test will not in itselfhave any effect on your acceptanceterms for insurance.)YesNoYesNom) Treatment or a positive testfor any disease which wastransmitted sexually?YesNoYesNon) Gastritis, stomach or duodenalulcer, blood in stools, fistula, pilesor any other stomach or boweldisorders?YesNoYesNoo) Jaundice, hepatitis, liver disorderor gall bladder disorder?YesNoYesNop) Blood, protein or sugar in the urine,kidney stones, infection or anyother disorders of the kidneys,bladder or genital organs?YesNoYesNoq) Anaemia or any other disorders ofthe blood?YesNoYesNor) Asthma, bronchitis, tuberculosis,pneumonia, coughing with bloodor any chest, lung or breathingdisorder?YesNoYesNo17FA 2005 FPI GT AppForm CS5.5.indd 175/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 9: Health questions (continued)First (or only) life assuredSecond life assureds) Back pain, neck pain, sciatica,joint pain, arthritis, repetitivestrain injury, gout or any otherdisorder of the muscles, bonesor limbs for which you haveconsulted a doctor, hospital,physiotherapist, osteopath,chiropractor or any other type ofmedical practitioner or for whichyou have taken time off work?YesNoYesNot) Any mental illness or eatingdisorder or have you attemptedself-harm or taken an overdose?YesNoYesNou) Any other feeling of depression,anxiety, stress or fatigue thatyou have reported to a doctor,hospital, nurse, psychologist orpsychiatrist or any other type ofmedical practitioner?YesNoYesNoYesNoYesNoFemale onlyv) Irregular or painful or unusuallyheavy menstruation, fibroids,cysts or any other disorder of thefemale organs?QuestionreferenceIf you answered Yes to any of thequestions above, please give detailsin this box to include disorder(s), date ofdisorder(s), duration, treatment, results ofinvestigations, time off work and when.Name(s) of clinic/hospital attendedAddress(es) ofclinic/hospitalattendedAre you: First (or only) life assuredSecond life assuredTelephonenumber(s)Fax number(s)18Friends Provident InternationalFA 2005 FPI GT AppForm CS5.5.indd 18Global Term Application form5/20/16 1:35 PM
FAILURE TO GIVE ACCURATE AND COMPLETE ANSWERS MAY RESULT IN NON-PAYMENT OF A CLAIMPart 9: Health questions (continued)First (or only) life assuredSecond life assured3 In the last five years, other than for those conditions you have already mentioned:a) Have you been exposed to therisk of HIV infection? (HIV canbe caught through unsafe sex,intravenous drug abuse, or bloodtransfusions outside Singaporeor surgery undertaken outsideSingapore.)YesNoYesNob) Have you had any medicalconsultation (for example, with adoctor, consultant, psychiatrist,clinic, physiotherapist orany other type of m
1 I have submitted the equivalent of sections 11, 12 and 13 of the Life Insurance Advisory Form (Life Insurance Association, Singapore). 2 Choose either of the following: a) The client(s) and I have completed the needs analysis according to the Life Insurance Association's Life Insurance Advisory Form.
Jacks Lane Energy Limited Aviva Corporation HILLSWOOD MANAGEMENT LIMITED Aviva Corporation AIEREF Holding 2 Aviva Corporation Kroknet S. a. r. l. Aviva Corporation Aviva Group Holdings Limited Aviva Corporation AIEREF Renewable Energy s.r.o. Aviva Corporation Lancashire and Yorkshire Rev
Aviva plc . Results . 2017 . Disclaimer . Cautionary statements: This should be read in conjunction with the documents distributed by Aviva plc (the “Company” or “Aviva”) through The Regulatory News Service (RNS). This presentation contains, and we may . Aviva plc - Results presentation FY 2017 .
Aviva plc Results 2018. . This should be read in conjunction with the documents distributed by Aviva plc (the “Company”or “Aviva”)through The Regulatory News Service (RNS). This presentation contains, and we may make other verbal or written “forward-looking statements”with respect to certain of Aviva’splans and current goals and .
The Accu-Chek Aviva Nano System Your new Accu-Chek Aviva Nano Meter is for quantitative blood glucose testing using Accu-Chek Aviva Strips. Suitable for self-testing. The Accu-Chek Aviva Nano Meter may be used by patients who test their own blood glucose as well as by healthcare pr
The ACCU-CHEK Aviva System Your new ACCU-CHEK Aviva meter and accessories work together to measure the amount of sugar (glucose) in your blood to help you and your doctor control your diabetes. The system includes: 2 ACCU-CHEK Aviva meter with battery ACCU-CHEK Aviva test strips and code key (may be sold separately)
The Strategic report is only part of the Annual report and accounts 2019. The Strategic report was approved by the Board on 4 March 2020 and signed on its behalf by Maurice Tulloch, Chief Executive Officer. More information about Aviva can be found at www.aviva.com Non-Financial Information Statement
The Accu-Chek Nano (not Aviva or Performa) and Accu-Chek Aviva Plus glucose systems are available within the United States ONLY, and use test strips branded as Accu-Chek Smartview and Accu-Chek Aviva Plus, respectively. These systems use the Mut Q-GDH (compatible)
The Accu‑Chek Aviva Plus System The Accu‑Chek Aviva Plus blood glucose monitoring system is intended to be used for the quantitative measurement of glucose (sugar) in fresh capillary whole blood samples drawn from the fingertips, forearm, upper arm, or palm. The Accu‑Chek Aviva Plus bl
