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

Are you self employed? (please tick)
If employed are you on a fixed term contract?

(iii) OTHER INSURANCES

For a life, accident or sickness policy, have you ever been refused or offered insurance on terms other than standard?
Do you have, or have you applied for sickness or accident insurance here or elsewhere? (Please tick)
a) I have sickness or accident insurance with dg mutual
b) I have sickness or accident insurance elsewhere
Have you ever resided outside the UK? (please tick)
c) I have previously applied for sickness or accident insurance with dg mutual
Have you any prospect or intention of residing outside the UK? (please tick)
d) I have previously applied for sickness or accident insurance with another company
Do you intend to engage in flying other than as a fare paying passenger? (please tick)
If you have this type of cover elsewhere will it continue?
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 :-

1. Anxiety, stress, depression, fatigue, breakdown or counselling?
2. Back, neck or shoulder pain, or disc problems?
3. Arthritis, joint, bone, ligament or muscle problems?
4. Chest, lung, breathing problems including asthma and bronchitis?
d. Has there been any increase or loss in your weight in the last year?
5. Heart disease, including heart attack, angina, chest pains or heart defects?
f. Have you ever smoked?
6. Digestive system, stomach, bowel or liver problems?
7. Any disorder of the genito-urinary system, kidney, bladder or prostate?
8. Blood pressure problems or blood disorders?
9. Skin disorders or allergies?
h. Have you been advised to reduce your alcohol intake?
10. Eye or ear problems? (You can ignore sight problems corrected by glasses or contact lenses)
i. Are you currently undergoing any treatment or awaiting any referral, tests, results or surgery?
11. Diabetes or impaired glucose intolerance?
j. Are you at present suffering from any disease, disorder or disability?
12. Debility, post viral/chronic fatigue syndrome or ME?
k. Have you ever taken or are you currently taking any drugs NOT prescribed by a doctor?
13. Migraine attacks, fits, faints, blackouts or paralysis or any disorder of the central nervous system?
l. Have you consulted any other health professional such as a Chiropractor or Osteopath?
14. Hernia, haemorrhoids or varicose veins?
m. Have you ever tested positive for HIV/Aids, Hepatitis B or C or any other sexually transmitted disease?
15. Tumours, cancers or growths
(including leukaemia or Hodgkin’s disease)?
16. Any gynaecological, menstrual, uterine or breast disease/disorder?
17. Any other illness, disability, mental or physical impairment or previous consulation that might be relevent to this application?
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
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.
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.
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.
2. Benefit from
3. Escalating, constant and reducing options (Further information here)
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
I do not wish to see the report before it is sent to the Society
Please tick this box if you gave advice to your client about this product
Application Form Mobile

Section 1

(i) PERSONAL DETAILS

Have you ever resided outside the UK? (please tick)
Have you any prospect or intention of residing outside the UK? (please tick)
Do you intend to engage in flying other than as a fare paying passenger? (please tick)
(ii) EMPLOYMENT DETAILS

Are you self employed? (please tick)
If employed are you on a fixed term contract?

(iii) OTHER INSURANCES

For a life, accident or sickness policy, have you ever been refused or offered insurance on terms other than standard?
Do you have, or have you applied for sickness or accident insurance here or elsewhere? (Please tick)
a) I have sickness or accident insurance with dg mutual
b) I have sickness or accident insurance elsewhere
c) I have previously applied for sickness or accident insurance with dg mutual
d) I have previously applied for sickness or accident insurance with another company
If you have this type of cover elsewhere will it continue?
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.

d. Has there been any increase or loss in your weight in the last year?
f. Have you ever smoked?
h. Have you been advised to reduce your alcohol intake?
i. Are you currently undergoing any treatment or awaiting any referral, tests, results or surgery?
j. Are you at present suffering from any disease, disorder or disability?
k. Have you ever taken or are you currently taking any drugs NOT prescribed by a doctor?
l. Have you consulted any other health professional such as a Chiropractor or Osteopath?
m. Have you ever tested positive for HIV/Aids, Hepatitis B or C or any other sexually transmitted disease?

Have you ever had :-

1. Anxiety, stress, depression, fatigue, breakdown or counselling?
2. Back, neck or shoulder pain, or disc problems?
3. Arthritis, joint, bone, ligament or muscle problems?
4. Chest, lung, breathing problems including asthma and bronchitis?
5. Heart disease, including heart attack, angina, chest pains or heart defects?
6. Digestive system, stomach, bowel or liver problems?
7. Any disorder of the genito-urinary system, kidney, bladder or prostate?
8. Blood pressure problems or blood disorders?
9. Skin disorders or allergies?
10. Eye or ear problems? (You can ignore sight problems corrected by glasses or contact lenses)
11. Diabetes or impaired glucose intolerance?
12. Debility, post viral/chronic fatigue syndrome or ME?
13. Migraine attacks, fits, faints, blackouts or paralysis or any disorder of the central nervous system?
14. Hernia, haemorrhoids or varicose veins?
15. Tumours, cancers or growths
(including leukaemia or Hodgkin’s disease)?
16. Any gynaecological, menstrual, uterine or breast disease/disorder?
17. Any other illness, disability, mental or physical impairment or previous consulation that might be relevent to this application?
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
Details
Dates
Question Ref
Details
Dates
Question Ref
Details
Dates
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.
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.
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.
2. Benefit from
3. Escalating, constant and reducing options (Further information here)
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
I do not wish to see the report before it is sent to the Society
Please tick this box if you gave advice to your client about this product
The Dentists’ & General Mutual Benefit Society Limited

Incorporated in 1999 under the Friendly Societies Act, 1992 (No, 456F). Member of the Association of Friendly Societies. Authorised and Regulated by the Financial Services Authority

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No. 4, Park Farm Barns, Chester Road, Stonebridge, Warwickshire, CV7 7TL

Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority