Group Income Protection Absence 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:

Postcode:

Member details

Title:

Surname:

Forename(s):

Gender

Date of birth (DD/MM/YYYY):

Address:

Postcode:

Telephone number 1 - mobile:

Telephone number 2:

Member’s email address - Please provide the member’s personal email address and NOT their work email address as we will use this to contact the member who may not have access to their work email during absence. If you provide an email address we will initially send the member a Member's Statement to complete via email which requires an e-signature. If no email address is provided we will issue the member's Statement by post which can delay the claim process:

Absence details

When was the member's first date of current absence? (DD/MM/YYYY):

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.

What category does the absence reason fall under? Please select the category that the absence falls under. Please note that if the claim is in relation to mental health or a musculoskeletal condition we will refer the claim to our Rehabilitation Team for an initial review of what support we can provide. If the claim is relation to cancer or other reasons we will review what support we can provide upon receipt of the Member's Statement.

Please fully describe the illness or injury that is preventing the member from working. If they’re off work for an operation or recovery from an operation then please include full details:

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

Please provide details of all absence related to this condition in the last 12 months, including their current/most recent period of absence:

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.

Please provide details of any non-medical reasons that may be impacting on the member's absence:

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

Employee's job title:

Employee/ Payroll ID (if applicable):

Business Unit / Division / Company Code (if applicable):

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 first join the Group Income Protection Insurance policy scheme (this may have been earlier than when the policy first switched to Legal & General)? (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.

What scheme category within the Group Income Protection policy is the employee a member of, if known?

Is the member in the company pension scheme? Yes No

Please provide the name of the pension scheme the member is a member of:

What date was the member first eligible to join the pension scheme? (DD/MM/YYYY):

What date did the member actually join the pension scheme? (DD/MM/YYYY):

If the member joined the pension scheme late, please provide the reason for this:

Financial details

Contractual weekly working hours (eg 37.5):

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

Basic annual salary (Please only include the numeric value eg 18,500.25):

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

Scheme Earnings in line with the insured earnings covered by the policy for the member (Please only include the numeric value eg 18,500.20):

Pensionable earnings (for calculating pension contributions, if insured - please only include the numeric value eg 18,500.25):

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? Yes No

The member is contracted out under a defined benefits scheme: Yes No

The member is contracted out under a defined contributions scheme: Yes No

The member is contracted in: Yes No

For Flexible/ Multiflex benefit schemes

Has the member Flexed their benefit amount?

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

Has the member Flexed their benefit period? (e.g. to State Pension Age)

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

Employer pension contribution % (Please only include the numeric value eg 5.5):

Member pension contribution % (Please only include the numeric value eg 5.5):

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

Account name:

Account number (eg 12345678):

Sort code (eg 123456):

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.

Print name:

Job title: