Group Income Protection Absence Notification Form

Intermediary details (if applicable)

Employer details

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

Member details

Absence details

Please provide the first date the member became absent work. If the member has had periods of linked absences of 5 consecutive days or more related to the same condition, pleas provide the initial date of absence and document the linked absences in the question below. You can also attached a copy of absence records at the end of this form.

Please provide as much information as possible to help us with the assessment of the absence and what support we can provide.

If the member has been absent for the same reason in the previous 12 months, please include the full dates and any additional details of absences for each period of 5 consecutive days or more. For example, date of absence for anxiety was 01 May 2020 and returned to work 10 May 2020.

Not all absences are primarily linked to a clinical illness and we need to fully understand these situations in order to assess the claim and ensure any support we provide is appropriate. If non-medical factors are impacting the absence such as carer duties for a family member or work related stress please provide as much information as possible.

Employment details

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

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.

Is the member in the company pension scheme?

Financial details

This is the number of hours a week that the member is expected to work under their contact

This is the member's contracted salary and doesn't take into account any bonsues or overtime that they might receive.

This is the figure that is used to calculate the member's pension contributions.

Are Employer National Insurance Contributions insured under the Group Income Protection policy?
The member is contracted out under a defined benefits scheme:
The member is contracted out under a defined contributions scheme:
The member is contracted in:

For Flexible/ Multiflex benefit schemes

Some of our schemes are flexible which means that the member can opt to flex their benefit either up or down.

Some of our schemes are flexible which means that the member can opt to flex their benefit so it can be paid for a longer period of time.

If pension contributions are insured

Benefit is payable monthly in arrears to the employer by direct credit. Please provide the following details:

Declaration by the principal employer as grantee of the policy

We declare that on the date of last attendance at work the member met the eligibility conditions agreed for the policy. We also declare the information we’ve provided in this form is correct to the best of our knowledge and belief. We confirm that we have a legal basis, to provide the information contained in this form to Legal & General and to receive from Legal & General any further information (including medical or health information) that is required as a result of this notification. Legal & General’s Sharing personal data of absent employees (555kb pdf) leaflet suggests different legal basis to consider. If the member’s absence results in the payment of Group Income Protection benefit under the policy, we, the grantees of the policy, ask you to make payment in accordance with the instructions given above.

Please note: We should be notified as soon as possible if the member returns to active employment.

To be signed by an official of the principal employer.