Membership Application

IMPORTANT NOTES – PLEASE READ BELOW BEFORE COMPLETING THIS FORM

When you complete this application form you should be aware that you must disclose all material facts. A material fact is any information that is likely to affect our decision to accept your application or the amount of subscription you pay. You are obliged to disclose this type of information to us, even if the application form has not asked specific questions about it. So, if you are unsure whether a fact is material or not, you must include it on your application form. Failure to disclose all material facts could result in your application being rejected, or you could find that your policy is invalid when you make a claim and no benefit will be payable. We will rely on what you tell us and you must not assume that we will clarify or confirm any information that you have provided with your medical attendants. Any rates, subscriptions or benefits indicated by the Society in any literature are based on an application being accepted on normal terms. The Society reserves the right to decline membership or offer membership on different terms based on information shown on the application form or received from other sources.

Application Form

Section 1

(i) PERSONAL DETAILS

(ii) EMPLOYMENT DETAILS

Surname

Profession or Occupation (please be precise)

Title

For how long have you been so employed?

If other, Please state

Are you self employed? (please tick)

Yes

Forenames

if yes, how long for?

Private Address

What is your average weekly gross income? (Net pre-tax earnings if self-employed)

Postcode

In the event of incapacity, for how long would you receive income or benefit from any source and at what rate?

Telephone

For how many weeks? If more than one source, give full details

If employed are you on a fixed term contract?

Yes

Business Address

If so, please provide the date the contract ends?

Business Postcode

(iii) OTHER INSURANCES

Business Telephone

For a life, accident or sickness policy, have you ever been refused or offered insurance on terms other than standard?

Yes

Business Email

If yes, please give details here or separately

Date of birth

Do you have, or have you applied for sickness or accident insurance here or elsewhere? (Please tick)

Place of birth (Town) (County)

a) I have sickness or accident insurance with dg mutual

Yes

If your place of birth is not in the UK, how long have you been a UK resident?

b) I have sickness or accident insurance elsewhere

Yes

Have you ever resided outside the UK? (please tick)

Yes

c) I have previously applied for sickness or accident insurance with dg mutual

Yes

Have you any prospect or intention of residing outside the UK? (please tick)

Yes

d) I have previously applied for sickness or accident insurance with another company

Yes

Do you intend to engage in flying other than as a fare paying passenger? (please tick)

Yes

If yes, please give details here or separately
Name of Company or Society

Please list any competitive sports, hobbies or activities likely to cause injury in which you currently or intend to participate.

Weekly Benefit

How did you hear about dg mutual?

Deferred Period

If referred by a dg mutual member, Please state the member’s name

If you have this type of cover elsewhere will it continue?

Yes

If in a journal, Please state which publication

Section 2

HEALTH DETAILS

Please answer every question. If you answer YES to any question please use the space provided at the bottom of Section 2 to give full details, including dates, time off work and current prognosis.

Have you ever had :-

a. Name and address of your Doctor

1. Anxiety, stress, depression, fatigue, breakdown or counselling?

Yes

b. How long have you been registered with your Doctor?

2. Back, neck or shoulder pain, or disc problems?

Yes

If less than 6 months, please provide your previous Doctor's details

3. Arthritis, joint, bone, ligament or muscle problems?

Yes

c. Please state your weight?

4. Chest, lung, breathing problems including asthma and bronchitis?

Yes

d. Has there been any increase or loss in your weight in the last year?

Yes

e. Please state your height?

5. Heart disease, including heart attack, angina, chest pains or heart defects?

Yes

f. Have you ever smoked?

Yes

6. Digestive system, stomach, bowel or liver problems?

Yes

If yes, how many per day?

7. Any disorder of the genito-urinary system, kidney, bladder or prostate?

Yes

If you no longer smoke, when did you give up?

8. Blood pressure problems or blood disorders?

Yes

g. What is your average weekly consumption of alcohol in units? (1 pint beer = 2 Units / 1 glass wine/measure of spirits = 1 Unit)

9. Skin disorders or allergies?

Yes

h. Have you been advised to reduce your alcohol intake?

Yes

10. Eye or ear problems? (You can ignore sight problems corrected by glasses or contact lenses)

Yes

i. Are you currently undergoing any treatment or awaiting any referral, tests, results or surgery?

Yes

11. Diabetes or impaired glucose intolerance?

Yes

j. Are you at present suffering from any disease, disorder or disability?

Yes

12. Debility, post viral/chronic fatigue syndrome or ME?

Yes

k. Have you ever taken or are you currently taking any drugs NOT prescribed by a doctor?

Yes

13. Migraine attacks, fits, faints, blackouts or paralysis or any disorder of the central nervous system?

Yes

l. Have you consulted any other health professional such as a Chiropractor or Osteopath?

Yes

14. Hernia, haemorrhoids or varicose veins?

Yes

m. Have you ever tested positive for HIV/Aids, Hepatitis B or C or any other sexually transmitted disease?

Yes

15. Tumours, cancers or growths
(including leukaemia or Hodgkin’s disease)?

Yes

16. Any gynaecological, menstrual, uterine or breast disease/disorder?

Yes

17. Any other illness, disability, mental or physical impairment or previous consulation that might be relevent to this application?

Yes

If you have answered YES to any of the questions in Section 2 please give full details.

Please note that failure to disclose relevant information could mean that we will reject your claim and your policy will be cancelled.

Question Ref

Details

Dates

Question Ref 1

Details 1

Dates 1

Question Ref 2

Details 2

Dates 2

Question Ref 2

Details 3

Dates 3

Question Ref 4

Details 4

Dates 4

Please give details below of the last time you sought medical advice if it was within the last three years (including the name and address of the medical practitioner if different to that given at 2a). Show dates, nature of incapacity and indicate any time away from work.

Please provide details if any of your immediate family have been diagnosed with or died from any of the following diseases before the age of 65.

Heart disease, stroke, diabetes, kidney disease, cancer, multiple sclerosis, raised blood pressure, Alzheimer's disease, motor neurone disease, Parkinson's disease and any hereditary disorder including Huntington's disease.

Father's Conditions
(If diagnosed with cancer, please advise the site)

Father's age at diagnosis

Father's age at death
(if applicable)

Mother's Conditions
(If diagnosed with cancer, please advise the site)

Mother's age at diagnosis

Mother's age at death
(if applicable)

Brother's Conditions
(If diagnosed with cancer, please advise the site)

Brother's age at diagnosis

Brother's age at death
(if applicable)

Sister's Conditions
(If diagnosed with cancer, please advise the site)

Sister's age at diagnosis

Sister's age at death
(if applicable)

Any additional Brother(s) and Sister(s) conditions
(If diagnosed with cancer, please advise the site)

Brother(s) and Sister(s)
age at diagnosis

Brother(s) and Sister(s)
age at death (if applicable)

Section 3

BENEFITS REQUIRED

Please indicate the amount and type of cover you require. Under the Limitation of Benefits clause the maximum you may apply for is 66% of net pre-tax earnings, less any other continuing income or insurances. Each bond provides £20 per week benefit and cover is available from £60 to £1200 per week.

1. Weekly Benefit Required

or Number of Bonds Required

All applications for benefit above £800 must be supported by proof of earnings. For the employed - Original printed payslips or P60. For the self employed - Original most recent accounts or Inland Revenue Notice of Assessment.

3. Escalating, constant and reducing options (Further information here)

Constant

Escalating

Reducing (N.B Reducing benefit is available for Day One cover only)

4. Retirement Age

Section 4

DATA PROTECTION

The information you provide will be held by the society in accordance with the Data Protection Act 1998 and it will be used in the administration of the policy.

A copy of the application form and any supporting documents, including financial and medical reports may be given to a reassurance company where the risk is shared with such a company.

We reserve the right to discuss any relevant aspects of your medical treatment or examination with the providers of those services.

Medical information provided will be used for underwriting and claims purposes only and your consent is required for us to use, hold and retain it. It will not be supplied to any other third party without your consent, unless it is lawful to do so.

Information may be released to your financial advisor to enable them to give you advice. This will not include medical information. If your financial advisor no longer represents you it is your responsibility to notify us.

Medical Reports Act 1988

Summary

Before we can apply for a medical report from your doctor we need your consent. Before signing in the space below you should know you have certain rights under the Access to Medical Reports Act 1988. The main points are as follows:

1. You can withhold your consent

2. You can see the report before it is sent to us provided that you apply to the doctor within 21 days or during the six month after that. The doctor may charge you a fee for providing the report to you.

3. You can ask the doctor if he will amend any part of the report which you consider to be incorrect or misleading. If the doctor is not in agreement, you may append your comments.

4. The doctor can withhold from you the report, or part of it, if he thinks you would be harmed by seeing it.

Full details of your rights under the Act are available on request.

Declaration and Consent to Obtain a Medical Report

I hereby declare that I am the person referred to in this Application Form, that I have read over my answers to all the questions and to the best of my knowledge and belief that the information provided is true and complete. I am aware that subscription increase with age and have noted the information relating to the Limitation of Benefits.

I have been informed of my statutory rights under the Access to Medical Reports Act 1988, as explained above, and in connection with my application, herby consent to The Dentists and General Mutual Benefit Society Limited being provided with medical information, including copies of my medical records, from any doctor that has attended me regarding my physical and mental health and agree that a copy of this consent shall have the validity of the original.

I undertake to inform the Society if I obtain additional similar insurance in the future or if any medical fact arises or changes before membership is in force.

(please tick one box below only)

I wish to see the report before it is sent to the Society

Yes

I do not wish to see the report before it is sent to the Society

Name
(block capitals)

Signature

Date

To be completed by Intermediary Firm
Name of Intermediary Firm

Please tick this box if you gave advice to your client about this product

Yes

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