l&g application

8/2/2019 L&G Application

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SECTION A Client and product detailsInitial Client details

i a. Full name and title

riddle nicies

' c. Date of birth

pipes, or nicotine replacements inthe last 12 months - including

; occasional use?

Client oneMi, Mrs, Miss MsO r, Rev, Othermiddle na m e(s ) in full

Surname

Male Female \

\ | jYes No

Client twoMr, Mis, Miss , Ms,Dr, Rev, O thermiddle name(s) in full

Surname

| Male Female

1 1= I*

, e. Employment status Full t imeemployeeSelfemployedUnemployed

Part limeemployeeRetired

Contract : Fulltimeworker i employeeMn< employed

House person Unemployed

Part t imeReti tedHouseperson

wod!Student :

a. Please indicate your occupationfrom the categories listed. i .yo.roccupctondoMm.i,

t h < * y a , e n o t W e , , d e d t o b e acomple te list

Client oneWorking in an off ice-type environment for at least 175 % of your typical working dayRetail - forexample, salesperson, refailer, shopworker or manager, (except market traders)Catering - for example, caterer, chef, cook,waiter, waitress, kitchen staffEducation - forexample, teacher, lecturer, headteacher, classroom assistant, nursery workersurgical, care rAnother category (including market traders)

useperso*. ' OT re ^ , o v^aenClient twoWorking in an off ice -type enviro75 % of your typical work ing dayRetail - for example, salespersonworker or manager, (except mawaiter, waitress, kitchen staffEducation - forexample, teacheteacher, classroom assistant, nursHealthcare - for example, nursinsurgical, carerAnother category (including ma

ment for at leastretailer, shop


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Does your job. or jobs if you hoves thai wolvt

listed opposite?tf 'Yes', please tick all that appfyIf 'No', please tick 'None of theabove'

Please also tell usyour job title if yenhaven't toid usalready in this formand you have ticked one of theoccupations in this question

Client one Client two

! The Aimed Forces 1 T h e Armed ForeThe offshore fishing industryThe offshore oil or gas production ndustry

a full time barna public house

Underground, for example mining, tunnelling

isports professionalNone of the above

The offshore fishing industryThe offshore oil or gas production industryAs a full time barman, baiin a public house

isports prce of the abovi

Is the total cover withLega l & General on your life greaterthan 800,000 fo r Li fe cover or500,000 for Critical Illness cover?

If you hove answered 'Yes' to question 8, please complete the following questionnaire(s), as applicable, BEFORE continuing with question 9:U- Personal Assurance Questionnaire [Part 4), f you're applying for Family Protection orMortgage Protection; and/or- Business Assurance Questionnaire [Part 5), if you're applying for Business Protection.

Have you taken out any Life orCritical illness cover or IncomeProfect ion Benefit with ANOTHERinsurer in the lost 12 months? (Pleaseany application that you didn'tproceed with)

If 'Yes', why are you completing this currentapplication? If 'Yes', why are you completing this currentapplication?T o replace the other application or policyFor comparison For other purposes

T o replace the other application or policypurposes only For other purposes

If 'For other purposes', what is the amount of caver If 'For other purposes', what is the amount of cin total under the other application^}? in total under the other application(s)?

10 In the fast 5 years have you lived,worked or travelled OUTSIDE the UK?(Please ignore the following:trips up to ! week, provided they wnot total more than 1 2 w e e k s in ayear)

tf 'Yes', please give the following details: If 'Yes', please give the following details;

Life Cover Critical Illness Cover !mConThV E

Lite Cover Critical Illness Cover (monthlyamount)

1i

Which country?In total, how longwere you there? 'was your lasf visit? yecother coun!ry(ies) to disclose?

"Y e s

monthsmonthsN o

Which country?In total, how longwere you there7 "wa s your last visit? yearsD o you have any yother country(ies) to disclose?

month,monthsNo

If 'Yes', please give the same details as above, Qff 'Yes', please give the same details as above,for the other country(ies), in Part 9 (Additional tor the other countryfies), in Part 9 (AdditionalInformation) before continuing with this section Information) before continuing with this section

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Client one11 During the next 2 years, do you

intend to live, work or travel OUTSIDEthe UK?holidays for up to 1month; businessnot total more than 12 weeks in oyear; any service as a member ofthe Armed Forces)^ - - t ! - ' n " w - V -Ir^-", _ ~ ! ~ d ul ^c-Man^-arhPC-r^re l ls .a^ :

12 If you regularly take part in any ofthe activities listed opposite, or youintend to do so within the next 6months, please tick all that apply.If none of these apply, please tick

,

W he nr !e c - ,> win-, aen t nt^nded to be c

Y e s Nof 'Yes', please give the following details:D o you plan to leave j Y Nthe UK permanently? | Yes If 'Yes', please advise when yo u intend to go andwhere you will live

If -No', will you be staying within the European Union,Australia or New Zealand? ' 1 Ye s 1 NoHow long do you planto be outside the UK n Weeks Daysthe next 2 years?Please list all the countries of islands outside theEuropean Union, United States of America, Canada, jAustra l ia or New Zealand that you are going o: [

I1

Caving or Potholing

or cabin crew)*Hang glidingMotor car sport*" Motorcycle sport"Mountaineering or Rock climbingdS0' Powe,boa, racingSailing Underwater divingAny Extreme sport, for example bungee or B A S ENone of the above

i-iy ng 'O IRPI than as a 'tre-paync; p a s s en ge r ) T

L Y e s _ J ^ 1f 'Yes', please give the following details:D o youplan to leave y Nthe UK permanently?If 'Yes', please advise when you intend to go andwhere youwill live

If 'No', will you be stayingwithin the European Union,Australia or New Zealand'? ' yes NoH ow long do you planto be outside the UK n Weeks Daysthe next 2 years?Please list all the countries or islands outside theEuropean Union, United States of America, Canada,Australia or New Zealand that you are going to:

coving or Po,ta,ngFlying (other than as a fare-paying passengerHang gliding

Mountaineeringo- Rock climbing:S" Pcwerboa, racingSail ing Underwater divingA ny Extreme sport, for example bungee or B A S Ejumping, canyoning, white water raftingNone of the above

Jv'dos av c - ' i O ' - i e ' t h e r a; a cc^ime or - J E p o r f o^ ar>Of veH-i- j! fo r -iv- *vp= -:""


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P A R T 2 About your health, lifestyle and family medical history0Please don't assume that we Genetic Testing.will contact your doctor for TheAssociationof British Insurers ( A B 1 ) have a policy on genetics and insurance.confirmation of medical details Currently, you only need to lell us about any genetic test results concerning Huntington's disease, for life

insurance ovei 500,000 in total. Ihis isbecause Ihe Governments Genetics and Insurance Committee(GAlC) has approved this test for insurers to use. The total is for any l i fe insuranceapplication being madenow together with any life 'nsurarce you hove already. You don't need to te l l usabout any other genetictest result.However, you must tell us if you are experiencing symptoms of, or are having treatment tor, a medicalcondition including any genetical ly inherited condition. Yaumust also tell us of any family history of amedical condition as askedfor in the relevant question in this application. If you want to tell i:s about anegative genetic test result, we'll be willing to consider this when setting your premium.A copy of tne A B 1 Code of Practice on Genetic Testing is available from us on request or from the AB Iwebsite www.abi.org.uk.

Client one Client two1 What is your height (without shoes)? f~

2 What is your weight (in indoor P .clothes)? j *g| I st lb I I k9 OR

3 If you smoke cigarettes how many I Av raa~nu"h f"do you, or did you, smoke on j cigarettes smoked a day | cigaret tes smoked a dayaverage each day?

4 What isyour average weekly j Average number of Unts, | Average number of unit

5 In the last 5 years has your averagihigher than your current average? tf 'Yes', please give the following details:

What wos the higher average I I What was the highei

Have you ever been medicallyadvised to reduce your alcoholconsumption? (f 'Yes', please give the following details: If 'Yes', please give the following details:

What was the r :: ' - ' .< " - 1 " -'' -~ f ' ! " "~r!n .-. ! - . - ; ' I'lv < < , : :

b. ycu haw had or been advi ed tc have any medical or jurgicalinvestigation, consultation, blood test, or follow-up?

c. you have not yet sought medical advice?

If you have answered 'Yes' to ANY part of question 12,please complete one of the Medical Questionnaires (Part 7} BEFORE continuing with question 13.O LP Connect 16/35


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13 Have any of your natural parents,brothers or sisters, before the age offrom any of the conditions listedopposite?(f 'Yes', please tick ail that applyIf 'No', please tick 'None of theabove'If unknown, please answer the'Unknown' question below.If 'Unknown Other', please tell us whyyou can't give details of the medicalhistory of your parents, brothers andsisters.

Client one ,Heart attack, AnginaStroke or Type 2DiabetesCancer of the BreastCancer of the OvaryCancer of the Colon[Bowel)Cancer of anothersite*Cardiomyopathy(primary disorder of theheart muscle]Multiple Sclerosis**Myotonic (Muscular)DystrophyPolyposis coli (FamilialPolycystic KidneyDiseaseMotor NeuroneDiseaseHuntington's DiseaseParkinson's DiseaseAlzheimer 's DiseaseAny O T H E R disorder

follow up orscreening***None of the aboveUnknown AdoptedUnknown Other

N o of Y o u n g e s t s*condrelatives age Vunges1affected affected a) ed

|

Unknown Nocontact |Details

Client two jHeart attack, Angina.Stroke or Type 2DiabetesCancer of the BreastCancel of the OvaryCancer of the Colon(Bowel)Cancer of anotherCardiomyopathy(primary disorder of theheart muscle)Multiple Sclerosis"Myotonic (Muscular)

> DystrophyPolyposis coli (Familialodenoinotous)Polycystic KidneyMotor NeuroneDiseaseHunfington's DiseaseParkinson's DiseaseAlzheimer's DiseaseAn y O T H E R disorderwhich runs in youtI family fo r which yo uare receiving regularfollow up orscreening***None of the aboveUnknown Adopted

I Unknown Other

No. of Y o u n g e s t affected affected^

I

Unknown No contactDetails

" If 'Cancer of another site', please tell us the part of the body affected by the 'primary' cancer, that is, whereit first occurred in the body. If more than one relative has had a 'Cancer of another site' please state alsites

** If 'Multiple Sclerosis', please tell us which family member(s) were/are affected. We do not need their ages

* ff 'Any O T H E R disorder which runs in your family fo r which you are receiving regular follow up orscreening' Pleaic give aelCiii cf ;he disorcter(!>' f c f wrrc- y o L > cxe receiving fel low uo a sc'ec-n-ng

14 Doctor's details

H

namePractice/clinic name andaddress (including postcode)

PostcodeTelephonenumber

namePractice/clinic name and I Asaddress (including postcode) Client1

PostcodeTelephonenumber

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PART 7 Medical Questionnairesfcj This questionnaire only applies if you have been asked in Part 2 to complete a Medical Questionnaire.

Medical Questionnaire 11 What question number, an d

question part (for example a, b, c)does this information relate to?

illness or injury j f g rowth or lump,

3 How long ago did the condition f irstoccur?

4 How often do you have symptoms?Please tick appropriate box - do notenter anything else in the box

5 H ow long ago was your iast majorattack? This means a suddenincrease in the seventy of symptoms,or need for treatment other thanyour usual medicine or tablets

6 In the last 5 years, have you hadsurgery or an operation, or anyother hospital admission (includingan overnight stay) for this condition?

7 In the last 5 years, in total, howmuch time off your normal work ordaily activities have you had for this

ago w as the most recent occasion?N ot apolicable i f you havea nswer ed '0 ' to question 7 above

9 Do you expect to have, or are youcurrently waiting for, surgery or anoperation, any other hospitaladmission (including an oyernightstay) or referral to a specialist forthis condition?

Client one Client twoPart 2: Question ( ) Part 2: Question ( ) 1If you have been asked to complete a Medical Quest annaire fo r more than on e condition, illness or njury inPart 2, you will need to complete o separate Medical Questionnaire for each one. Use this page to give detailsof the first condition, use Medical Questionnaire 2 oppos te for the second an d then use the AdditionalIn format ion sect ion (Part 9 . or photocopy th s page, to g ve the se me de tails for any furthercondition(s)

| ]yea,, month, years months

'

No,ymptomsnow YearlyMonthly Weekly Daily

No symptoms nowMonthly Weekly

Never hod Current ya major attack or at presentOther years months

Never had Currena major attack or at pOther ye

Surgery 01 operation Y e s No Surgery or opera! on

YeailyDaily

y

mnthS

Y e s No1 1

If 'Yes', how long ago? years months j H 'Yes', how long ago? years monthsOther hospital admission I |(including overnight stay) ] Ies NoIf 'Yes', how long ago? years months

Other hospital admission(including overnightstay) Yes No

weeks days week,f yo u haven't taken time off, please enter '0'

years months yearsf you are currently of f wo rk , please enter '0 '

Surgery or operat on Yes NoIf -Yes', when?O ther hospital admission(including overnight stay) No

Surgery or operat on

days

month,

Y e s I,.If 'Yes', when?O ther hospital admission(including overnight stay) Yes No

10 Are you currently receivingtreatment for this condition? Y e s No

If 'Yes', please gphysiotherapy. 1

Ye s Nove the name of medicine or tablet, or details of other treatment, for exmore than one treatment, please state them all

ample

1 1 Do you have an y more medicalconditions to disclose as a result ofanswering 'Yes' to a question in g Tes,peasecorTlptete the second Medical Q ft 'Yes', please complete the second MedicalPart 2? Questionnaire opposite before returning to Part 2 Questionnaire opposite before returning to Part 2

If you do have another medical condition to disclose, please complete the second Medical Questionnaire opposite. Otherwise, please now return to Part 2 and complete theremaining medical questions.


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Medical Questionnaire 21 What question number, and

question part (for example a, b, c)does this information relate to?

Nome of actual medical conditioiillness or inury If growth or lump.

Client on e

Us e this page to give details of a second conditiono-- photocopy this poge. to give the same details for

| Part 2: Question find then use the Additional Inforrrany further medical condition(s)

3 How long ago did the condition f i rs toccur?

How often do you have symptoms? r~smDt"lease tick cppropr a'e box - do notenter anything else in the box I Monthly

attack? This means a suddenincrease in the severity ofsymptoms,or need for treatment other thanyour usual medicine or tablets

ver had

In the last 5 years, have you hadsurgery or an operation, or anyan overnight stay) for this condition? !

Surgery ot operation

Other hospital admission(including overnightstay)ll'YW.howlonoago? yec

Yes

Yesrs

No

No

months

Surgery or operation

Othet hospital admission(including overnight stay)If 'Yes', how long ago? yec

Yes

Yes

"

No

No

monlhs

7 In the last 5 years, in total, howdaily activities have you had for this If you haven't taken time off. please entei

If you have had time off, how longago was the most recent occasion?Not cpolicable 'f you hove |fycnswereo 0 to que on, coove

9 Do you expect to have, or are youcurrently waiting for surgery or anoperation, any other hospitalstay) or referral to a specialist for

Surgery oroperationIf 'Yes', when?Other hospital admission(including overnight stay)If 'Yes', when?Referral lo a specialistII 'Yes', when?

Yes

Yes

No

EN 0 |

Surgery or operation Ye sIf 'Yes', when?Other hospital admission y(including overnight stay)If 'Yes', when?Referral to a specialist YesIf 'Yes', when?

NO

No

No

10 Are you currently receiving

II 'Yes', please give the name of medicine or tablet, or details of other treatment, for *physiotherapy. If more than one treatment, please state them all

11 Do you have any more medicalconditions to disclose as a result otanswering 'Yes1 to a question inPart 2 ? | IfYes', please give the same details as above,for the other medical condition(s), in Part 9

(Additional Information) before returnng toPart 2

| (f 'Yes', please give the same details as above,for the other medical condition(s), in Part 9(Additional Information}before returnngtoPart 2

Please now return to Part 2 and complete the remaining medicalquestion!

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1 PART 10 Client Declaration and Consent Please ensure that you have read the notes at the beginning of this form. You must read carefully the answers you have given to the questions before accepting the fallowing Declaration. The nformation you give will form the basis of your contract with Legal & General. If you have passed a half birthday while the application isbeing processed, the terms may differ from those originally quoted. In most instances the payments will be as originally quoted. Legal 8. General may sometimesoffer revised terms and/or

premiums and very occasionally may not be able to of fe r the benefits requested, legal 8. General will inform you as soonas possible if this is the case. Please remember that all items of information asked for In this applicationare material facts which are taken into account whenassessing acceptance of the application and in calculating the premium. Please also remember that if you do not answer thequestions truthfully and accurately itwill very likely mean thata claim will be declined and the policy(tes) cancelled. If you arenot sure if any informationis relevant, pleasedisclose it anyway. If you have given information to Legal& General in the past,

please disclose itagain. If necessary, please return to the questions and amend your answer in the appropriateplace. Legal & General will try to rely on the information you provide and youmust notassume that they will alwaysclarify thatinformation with your doctor (GP). However,as part of their administrative procedures, Legal & General may ask for a reportfrom your GP to check medical disclosures. Legal 8. General may ask you to contact your doctor if they are waiting forreports which they have asked for. If Legal 8. Generalasks you to attend a medical examination, it may be necessary to share the application Information w ithanother company which they have authorised. If so, that company will make the arrangements for the examination to fake place.

AB Clients-;f is mipofiwif ma r yo-jrec^anoaccep/ait o f Fhe fo i 'OA ' i naca raa ' -O Dn i , I f v O u ar s ' n;,- r< ? of r-,n-.-Hnc c- have

i'hat ( clainI /We agree to immediately inform Legal & General In writing of any changes tothe following answers on the applicationthat occur before the policy starts,about: medical disclosures; occupation; pastimes; country of residence (other than for holidays); family history.I/We understand that failure to do so may result in the contract beingdeclared void and the benefits due under ihe policy not being paid.I/We agree to Legal . General getting relevant information from another

For all applicantsData ProtectionUse of personal nformation:Legal , GenertI/We understand that Legal & General willus

I. Providing me/L

this box ii you DO w|1Client twochtai

sharing it with a reinsurer and/or third party administrator. See also theparagraph headed 'Sensitive data'.I/We understand that Insurers share information with each other to preventfraudulent claims via a Register of Claims and that a list of participants savailable on request. The nformation I/we supply in this application, togetherinformation in I'ne event of a claim, wll be given to the Register and mavailable to other participants.I/We agree that if the policy is to he set up as joint l ives, i' will be own?I/We confirm that I/we have received and read the Key Features for tniproduct. I/We understand the f ea tu res and risks of Ihe producl and areappied for, tnis applies to all).For Income Protection Benefit ortlyDefinition of earningsYou should only cover earningsand benefits that you willyo u are unable to work. longer receive If

nings for P A Y Employed - earnings ate defined as your annual pre tax eassessment purposes and can Include your PIIdbenefits.Self employed - earnings are defined qsyour share of annual pre tax profit. Thismeans your share of the total Income from the business, less the expenses fromrunning thai business as permitted by the HMRC guidelines. Please refer to yourKey Features Document for full Information.I understand that my monthly benefit can't be mare than 60% of the f i rst30,000 of my pre-incapacity earnings and 50% of my pre-incapacity earningsover 30,000, up to a maximum of 16,667 permonth, I understand that if, atthe time of a claim, the level of benefit stated in rny policy exceeds thisI understand that i! I have applied for Housepersans cover, the maximummonthly benefit is1.667 per month.

(b) send me/us marketing information about their products and services andproducts ana services ot companies In the Legal E. Geneial grot;p and otthird parties whose products and services Legal , General offers to itsclients.

Ry signing this Declaration I/we agree to receive the information as describedin (bj obove by post or telephone, unless I/we indicate othe'wise by writingw i t h my/our lull caniacl details to Legal 5, Genera! Assurance Sociely.P O B o x 274, Bangor, BT I 9 7WZ.Access: I/We understand that I/we have the right to ask for a copy of my/ourinformation please write to Legal & General at UKSO Business Standards.Legal S General Assurance Society, Brunei House, Cardiff, CF24 OEB.Approaching fraud prevention agencies:Legal & Generalwllchecdetails, with fruud prevention agencies. If ialse or inaccurate informprovided and fraud is identified details will be passed to fraud pre

my/o

sforc editjnts imanaging credit anc

ium recovering deb; checking details on proposals and claims tor all types of insurance; cnecking details of job applicants and employees.

O LP Connect 31/35


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I/We understand that I/we can contact Legal & General at Group FinancialCrime, Legal & , General House, Kingswooci , Tadworth, Surrey KT20 6EU if I/we

jhcaTion, solely for the purposes o! alloivin

n collected vi a this appl'cation) may be

I/We have been told that Legal & Gempolicy documentation.I /W < = have been told that the contractand Wales.I /We understand that the full terms andAccess to Medical Reports: Notice of your StatutoryRights under the Access toMedical Reports A ct 1988, the Access to Personal Files an d Medical Reports{Northern Ireland] Order 1 9 9 1 , and the isle of Man Arcess to Health Recordsana Reports Act 1993.

Before they can ask any doctor that you have consulted to fii! in r: repon theyneed your permission under the above Acts. You do not need to give your permission, out if you do noi

Legal & General may not be able to go ahead with your application. This You can ask o see the reporl before the doctor returns it, inwhich case

please tick the box below, right. Ityou do this the doctor can see that yourequire access and keep Ihe report for 21days sothat you can arranae tosee it. If you have not made arrangements to see the report within this timethe doctor will send the Deport to Legal & General,

If you choose not to see the report at this stage you may ask the doctor forof the report to the doctor if you ask to see it at a later date

If you think that any part of the report is not correct or ;s misleading youmay ask the doctor to amend it. If the doctor refuses to mate the

Thedoctor can withhold access to the report if he or she eels 'hat it wouldTh e medical reporl your doctor fills in asks about the following: your current health

- the results of referrals or tests you are waiting for

your past health- details o* any relevant illness, trauma, or referrals for specialist advice or

treatment, hospital admissions, coi-.ss/Italians with your GP or any otherhistory of -

degenerative (gradually worsening) diseases;- tnusculoskeleial disease or injury, for example arthrit is, rheumat ism,

psychosis (a mental disorder where yo u lose contact with reality), s t r e s s- suicidal thought; or a i tempfs at suicide; o'- conditions related to drug or alcohol misuse, or smoking, or chewingtobacco.

- detailsof any biopsies, blooa tests, electrocardiograms (heart tests),height, weight if measured in the last two years, urinalyses (test on urine),- any blood pressure readings in the last three years.

any histoiy of disease among your parents or brothers or sisters that youhave told your doctor about. negative tests for HIV hepatitis 6 or C,

Lega l 8. General:

setting premiums at standard rales.to the process of getting, assessing or storingmedical information, pleasehe process of getting, assessing or storing medca informatiwrite to: Claims and Underwriting Director, Legal 8. Genera! As sLimited, City Park. The Droveway, Hove BN 3 7PY.MedicalCo ent: If Legal . General decide they need to obtain a report

have applied for. I/We authorise those asked to provide medical infT h i s torm allows Legal & . General to gather medical reparis within six months ofthe start of the policy, or to support any claim made on tne policy proceeds.

V . Legal & . General need to obtain a report f rym my/our doctor: I/Wedo not want to see the reporl before it is sent to Legal & General

Client oneQClient two j j I/Wedo want to see the report before it is sent to Legal & General

Client one j~|Client two [~~|

Please remember that afi ilems of Information requested In this application form are material facts which are taken info account W hen assessing acceptanceo f the application and In calculating the premium.If you do not give any of this information or If you mis-state any information. It will very likely mean that a claim will be declined and the pottcy(ies) cancelled.If you are uncertain as to the relevance of any such Informationot Ifyou believe that there U any other Information which may be relevant, please return tothe questions and answer in the appropriate place. If you have given Information to Legal 8. General in the past please disclose it again.I /W e confirm that I/we accept this Declaration and Consent, my/our rights under the Access to Medical ReportsAct, and the notes section at the beginning ofthis form.By signing this Declaration I/we agree to all of the contents.Client one Client tw o

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PA R T 11 Direct debit instructionThis direct debit instruction must be fully completed, signed an d dated before your application can be processed.

f?I& Aieneralt Name and full postal address of

your bank or building societybranch

2 Bank account name

3 Bank or building society accountnumber

4 Branch sort code

5 Reference numberiPreferred colectiondate each7 Instruction to your bank or

buldingsociety

Banks and buldingsocieties maynot accept direct debit instructionsfor some types of account

Instruction toyour bank orbuilding society topaydirect debits rtJpJJO rig inator 's Identification Numbers

8 t o J 6 J 1 J 6 J 2 | 9 I j 3 1 4 I 8 [ s l l j f j l U j a ] 9 9 6 8 4 1 1 1

To: Bank o r Building Soc i e t yAddress

Postcode

!

1 | - f | | - | |

'lease pay Legal 8, General Assurance Society Limited direct debits from the account detailed in thisnstruction subject to the safeguards assured by the Direct Debit Guarantee,understand that this instruction may remain with Legal 8, General Assurance Society Limited and, f so.

details wll be passed electronically to my bank or bulding society.1 ISignature and date | Signature and date :

; =L JQ If you want to pay for another product(s) by direct debit from a different bank account(s), please complete another direct debit instruction foreach bank account(s).Otherwise, this is all the informationwe need, please now cut off the Drect Debit Guarantee below and keep it somewhere safe. Use the

Cut off here and keep the Direct Debit Guarantee somewheresafe

* The Direct Debit Guarantee - this guarantee shoufd be detached and retained by the payer This Guarantee is offered by all banks and buldingsocieties that accept instructions to pay Direct Debits.

DIRECTFDebit

General If there are any changes o the amount, date or frequencyof your Direct Debit, Legal 8, General Assurance Society Ltdwill notify you five workingdays in advance of your account being debited or as otherwise agreed. If you request Legal &General Assurance Society Ltd to collect apayment, confirmation ot the amount and date will be given to you at the time of the request.

If an error ismade in the payment of your Direct Debit by Legal 3. Genera! Assurance Society Ltd or your bank or building society, you are entitledto a lul and immediate refund of the amount paid from your bank or building society- If you receive a refund you are not entitledto, you must pay it back when Legal & General Assurance Society Ltd asks you to

You can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please alsonotify us.

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l&g application

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