Critical Illness Cover Notification Form

Intermediary details (if applicable)

Intermediary's name:

Intermediary's telephone number:

Intermediary's email address:

Employer details

Principal employer's name:

Employer's name (if different):

Group policy number G (please only type the 8 numerical digits after the G):

The group protection policy number will start with a G and is followed by 8 numbers.

Employer's contact name:

Employer's contact number:

Employer's email address:

Employer's contact address:

Employer's postcode:

Member details

Title:

Surname:

Forename(s):

Gender

Date of birth (DD/MM/YYYY):

Address:

Postcode:

Telephone number 1 - mobile:

Telephone number 2:

Personal email address: Please ensure their personal email address is provided and NOT their work email address. We will use this to contact the member who may not have access to their work email. If an email address is provided, we will then be able to issue a Member Claim From directly to the Member via email, which they can complete and sign via e-signature.If no email address is provided we will issue the Member Claim Form by post which can delay the claim process.

Employment details

On what date did the member start service with the employer? (DD/MM/YYYY):

This is the date that the member started their contract of employment.

On what date did the member join the scheme? (DD/MM/YYYY):

This is the date that the member joined the Group Income Protection scheme, it may not be the same date as they started employment as some schemes have qualifying periods.

Membership category (if known):

Membership category entry date (if known) (DD/MM/YYYY):

Employee's job title:

Location of member’s employment:

On what date was the member last actively at work? (DD/MM/YYYY):

This is the date the member was last at work before they went absent.

Member's actual earnings (Please only include the numeric value eg 18,500.25):

Member's scheme earnings. (Please only include the numeric value eg 18,500.25):

Amount being claimed under the policy. (Please only include the numeric value eg 18,500.25):

If the member's level of benefit has changed since joining the scheme, please provide details:

If the member is not still in your employment and included in the scheme, please provide details:

If the member is the subject of the claim have they been absent before with a same or similar condition?

If you answered yes to the above please provide details:

Member's partner or child details (if applicable)

(eg. If the claim being submitted is for the employee’s spouse, registered civil partner, unmarried partner or child (where covered):

Surname:

Forename(s):

Date of birth (DD/MM/YYYY):

Relationship to member:

Date they became eligible for inclusion (DD/MM/YYYY):

Declaration by the principal employer as grantee of the policy

We declare that the above statements are accurate and complete and that the above member is eligible, in accordance with the terms and conditions of the policy and the plan issued by Legal & General Assurance Society Limited (Legal & General).

We confirm we have the explicit consent of the person(s) named in this form, or have other legal basis, to provide Legal & General this information and any further information (including medical or health information) that is required.

By signing this declaration you confirm the Insurer is:

fully discharged from its liabilities to you in respect of benefits for the insured member arising from the policy, and
fully indemnified from any further claim in this respect’

To be signed by an official of the principal employer.

Print name:

Job title:

Group Critical Illness Claim Notification Form