SECTION A Client and product details

Initial Client details

Client one
i a. Full name and title riddle nicies Mi, Mrs, Miss Ms Or, Rev, Other middle name(s) in full

Client two
Mr, Mis, Miss, Ms, Dr, Rev, Other middle name(s) in full

Surname

Surname

Male ' c. Date of birth

Female

| Male

Female

\
Yes

|
No

1 =

1 I*
Part time wod!^ Retited Houseperson Student :

; , e.

pipes, or nicotine replacements in the last 12 months - including occasional use? Employment status

Full time employee Self employed Unemployed

Part lime employee Retired House person

Contract worker
M

: Fulltime i employee employed Unemployed

n<

useperso*. 'OTre^, o v^aen

Client one
a. Please indicate your occupation from the categories listed .i.yo.roccupctondoMm.i, Working in an office-type environment for at least 75% of your typical working day Retail - for example, salesperson, refailer, shop worker or manager, (except market traders) Catering - for example, caterer, chef, cook, waiter, waitress, kitchen staff Education - for example, teacher, lecturer, head teacher, classroom assistant, nursery worker surgical, carer Another category (including market traders) tf 'Healthcare', please selec auxiliary, paramedic, practice nu se, dental nurse, district nurse, midwife Surgeon, anaesthetist, obsletricia n, gynaecologist, dentist, dental hygienist, carer, ca re assistant, social worker, physiotherapist ctitioner hospital doctor (other than surgeon, anae sthetist, e above). psychiatrist, osteopath If 'Another category', pleose give details: ! 1

Client two
Working in an office-type enviro ment for at least 75% of your typical working day Retail - for example, salesperson retailer, shop worker or manager, (except ma <et traders) chef, cook, waiter, waitress, kitchen staff Education - for example, teache lecturer, head teacher, classroom assistant, nurs ;ry worker Healthcare - for example, nursin g, medical. surgical, carer Another category (including ma ket traders) If 'Healthcare', please select: Nurse, staff nurse, charge nurse, s stei, mat re auxiliary, paramedic, practice nu se, denta nurse, district nurse, midwife Surgeon, anaesthetist, obstetricia n, gynaecologist, dentist, dental hygienist, carer, ca re assistant, social worker, physiotherapist Physician, medical or general pro ctitioner, h ospiial sthetist, obstetrician or gynaecologist - se e above), psychiatrist, osteopath If 'Another category', please

th<*ya,enotWe,,dedtobea complete list

OLP Connect 4/35

Client one
Does your job. or jobs if you hove s thai wolvt ! The Aimed Forces listed opposite? tf 'Yes', please tick all that appfy If 'No', please tick 'None of the above' The offshore fishing industry The offshore oil or gas production industry a full time barn a public house

Client two

1 The Armed Fore The offshore fishing industry The offshore oil or gas production industry As a full time barman, bai in a public house

Underground, for example mining, tunnelling

i sports professional None of the above Please also tell us your job title if yen haven't toid us already in this form and you have ticked one of the occupations in this question

i sports prc e of the abovi

Is the total cover with Legal & General on your life greater than 800,000 for Life cover or 500,000 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), if you're applying for Family Protection or Mortgage Protection; and/or - Business Assurance Questionnaire [Part 5), if you're applying for Business Protection. Have you taken out any Life or Critical illness cover or Income Profection Benefit with ANOTHER insurer in the lost 12 months? (Please any application that you didn't proceed with)

If 'Yes', why are you completing this current application? To replace the other application or policy For comparison For other purposes

If 'Yes', why are you completing this current application? To replace the other application or policy purposes only For other purposes

If 'For other purposes', what is the amount of caver in total under the other application^}? Life Cover Critical Illness Cover !mConThV^ 10 In the fast 5 years have you lived, worked or travelled OUTSIDE the UK? (Please ignore the following: tf 'Yes', please give the following details: trips up to ! week, provided they w not total more than 12 weeks in a year) Which country? In total, how long were you there? was your lasf visit? other coun!ry(ies) to disclose? '
yec

If 'For other purposes', what is the amount of c in total under the other application(s)? Lite Cover Critical Illness Cover (monthlyamount)

1i

If 'Yes', please give the following details; Which country?

"
Yes

months months
No

In total, how long were you there7 was your last visit? Do you have any other country(ies) to disclose?

" years
y

month, months
No

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

Q ff 'Yes', please give the same details as above, tor the other countryfies), in Part 9 (Additional Information) before continuing with this section

OLP Connect 12/35

Client one
1 1 During the next 2 years, do you intend to live, work or travel OUTSIDE the UK? holidays for up to 1 month; business not total more than 12 weeks in o year; any service as a member of the Armed Forces)
Yes

No

LYes _J^ 1
f 'Yes', please give the following details:
N

f 'Yes', please give the following details: Do you plan to leave the UK permanently? j |
Y Yes

Do you plan to leave the UK permanently?

If 'Yes', please advise when you intend to go and where you will live

If 'Yes', please advise when you intend to go and where you will live

^--t!-'n" w-V -Ir^-", _~!~d u

l^c-Man^-arhPC-r^rells.a^:

If -No', will you be staying within the European Union, Australia or New Zealand? How long do you plan to be outside the UK in the next 2 years? ' 1 Yes 1 No

If 'No', will you be staying within the European Union, Australia or New Zealand'? How long do you plan to be outside the UK in the next 2 years? j [ ' yes
No

Weeks

Days

Weeks

Days

Please list all the countries of islands outside the European Union, United States of America, Canada, Australia or New Zealand that you are going o:

Please list all the countries or islands outside the European Union, United States of America, Canada, Australia or New Zealand that you are going to:

I 1

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

Caving or Potholing or cabin crew)* Hang gliding Motor car sport*" Motorcycle sport"

coving or Po,tal,ng Flying (other than as a fare-paying passenger Hang gliding

Mountaineering or Rock climbing

Mountaineering o- Rock climbing: S^" Sailing Pcwerboa, racing Underwater diving

^dS00' Sailing

Powe,boa, racing Underwater diving

Any Extreme sport, for example bungee or BASE None of the above
Whe !e c - ,> w nr in-, aen t nt^nded to be c

Any Extreme sport, for example bungee or BASE jumping, canyoning, white water rafting None of the above

i-iy ng 'OIRPI than as a 'tre-paync; passenger) T Jv'dos av c-'iO'-i e'ther a; a cc^ime or -JE porf o^ ar>
Of

veH-i- j! for -iv- *vp= - : ""<" na r.-ih'irr

lf you have ticked any of the activities listed in question 12, please complete the Hazardous Part 2. If you have ticked 'None of the above', please now continue with Port 2.

iuits Questionnaire (Part 6) BEFORE continuing with

OLP Connect 13/35

PART 2
0

About your health, lifestyle and family medical history

Genetic Testing. The Association of British Insurers (AB1) have a policy on genetics and insurance. 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 is because Ihe Governments Genetics and Insurance Committee (GAlC) has approved this test for insurers to use. The total is for any life insurance application being made now together with any life 'nsurarce you hove already. You don't need to tell us about any other genetic test result. However, you must tell us if you are experiencing symptoms of, or are having treatment tor, a medical condition including any genetically inherited condition. Yau must also tell us of any family history of a medical condition as asked for in the relevant question in this application. If you want to tell i:s about a negative genetic test result, we'll be willing to consider this when setting your premium. A copy of tne AB1 Code of Practice on Genetic Testing is available from us on request or from the ABI website www.abi.org.uk.

Please don't assume that we will contact your doctor for confirmation of medical details

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

Client two

What is your weight (in indoor clothes)?

P j

. *g|

st

lb

I I

OR

If you smoke cigarettes how many do you, or did you, smoke on average each day? What is your average weekly

I Av raa~nu"h f" j cigarettes smoked a day

cigarettes smoked a day

Average number of Unlts,

Average number of unit

In the last 5 years has your averagi higher 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 medically advised to reduce your alcohol consumption?

(f 'Yes', please give the following details:

If 'Yes', please give the following details:

What was the r<

Have you ever tested positive for HiV, Hepatitis B or C, or are you woiting for the results of such a test? Please tick all that apply. If none of these apply, please tick 'None of the above*. (A negative HIV or Hepatitis test result will not, of itself, have any insurance).

Tested positive for HIV Tested positive for Hepatitis I ssted positive for Hepatitis C aiting results of HIV test Awaiting results of Hepatitis B It Awaiting results of Hepatitis C test None of the above If awaiting results of a Hepatitis B or Hepatitis C test, please give the reason for the test: If awaiting results of a Hepatitis B or Hepatitis C test, please give the reason for The iest:

Client two
tn the lost 5 years have you tested positive or been treated for any sexually?
Yes

No

Yes

No
ve the following details:

Name of the disease How many times have you had this? How long ago was this? Are you fully recovered? years Yes months No j No
N

1 Name of the disease 1 How many times have you had this? How long ago w s this? Are you fully recc vered? Do you have any other condition(s) years Yes
y

months No .,

Do you have any other condition(s) y to disclose under this heading? | Tes

If 'Yes', please give the same details as above, for the other condition(s), in Part 9 (Additional Information) before continuing with this section

Q If 'Yes', please give the same details as above, for the other condition (s), in Part 9 (Additional Information) before continuing with this section

recreational drugs, other than connabis, for example ecstasy, cocaine, or heroin?

When answering questions 10, 11 and 12, if you a However, there is no need to state the same med

any medical condition you have had, please disclose it anyway, e when answering the questions.

Client one 10 Have you ever had any of the conditions listed opposite? a. b. c. ;ot intended to be c d. Heart attack, angina, or any other heart conditi heart abnormalities from birth, cardiamyopathy A stroke, transient ischaernic attack (TIA) or Any other condition affecting the arteries, ii arteries in the legs or of the aorta, for example at blockage, narrowing or inflammation? Cancer, Hodgkin's disease, lymphoma, brain or spinal tut

Client two

Multiple scle retrobulbor i

;ion disturt epilepsy c

Muscular dyslrophy, paralysis, cerebral palsy, or any neurological condition, for example motor neurone disease, Parkinson's ; that has required refet or a psychiatrist?

" "

If you have ai iwered 'Yes' to ANY part of question 10, ptease complete one of the Medical Questionnaires (Pan* 7) BEFORE continuing with question 11.

OLP Connect 15/35

11

In the lost 5 years have you had conditions listed opposite? c. ''' "" '" ' ' '" "' ' " '' Where examples are snown. they ore n o f jntencjgrf pO be a complete list Chest pain, irregular heart beat, raised blood pressure, raised cholesterol, or condition affecting your veins, for example palpitations, deep vein thrombosis'? I d. Any numbness, tingling, dizziness, balance problems, persistent pins and needles or facial pain olher than dental pain? oint o Jb e f ex pie rheumatoid arthritis, sciaticc ? y Yes No L i No . [ "1

I Yes

h.

Any blood condition, for example one

Disease deafne<o ii i j fi i Lite Ci-

int

k.

Any condition affecting your eyes or vision, not wholly corrected by spectacles or lenses, for example cataract, blindness? .-,-';: - -\^Any condition affecting your lungs or breathing, for example asfhma, j Yf

t.

Any other condition or symptoi which has needed a ECC, MRi, or CT scan?

11 p is only applicable to females: which you have needed (urther investigations, tests, advice, or for which you hove not yet been discharged from follow-up? 11 q and llr are only applicable if you have selected Income Protection Benefit or the waiver of premium benefit option:

Q If you have answered 'Yes' to ANY part of question 11, please complete one of the Medical Questionnaires [Part 7) BEFORE continuing with question 12. 12 In the lost 12 months have you had any medical condition, symptoms, illness or injury not mentioned previously for which:
a

yOU have been prescribed any treatment? v\hen crtiiwe' ng ^his you ccn igmie nhrc- txrl. i T^-: /.'-'.t 'Jir" c, !^go- c.'-.o-o-;-o-:i . d -> --.-^,- - : -..--.-.-,i- r.r-u ,-- ?,r.n.:.'-g '"-'- ' ' ""'."'-- : ~'-i> : : '-' .< " - 1 " -'' -~ f ' !""~r!n.-. !-.-;' I'lv < <, ::

b.

ycu haw had or been advi ed tc have any medical or jurgical investigation, 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. OLP Connect 16/35

Client one
13 Have any of your natural parents, brothers or sisters, before the age of from any of the conditions listed opposite? (f 'Yes', please tick ail that apply If 'No', please tick 'None of the above' If unknown, please answer the 'Unknown' question below. If 'Unknown Other', please tell us why you can't give details of the medical history of your parents, brothers and sisters. Heart attack, Angina Stroke or Type 2 Diabetes Cancer of the Breast Cancer of the Ovary Cancer of the Colon [Bowel) Cancer of another site* Cardiomyopathy (primary disorder of the heart muscle] Multiple Sclerosis** Myotonic (Muscular) Dystrophy Polyposis coli (Familial Polycystic Kidney Disease Motor Neurone Disease Huntington's Disease Parkinson's Disease Alzheimer's Disease Any OTHER disorder

No of Youngest s*cond relatives age Vunges1 affected affected af)^ed

Client two
Heart attack, Angina. Stroke or Type 2 Diabetes Cancer of the Breast Cancel of the Ovary Cancer of the Colon (Bowel) Cancer of another Cardiomyopathy (primary disorder of the heart muscle) Multiple Sclerosis" Myotonic (Muscular) > Dystrophy Polyposis coli (Familial odenoinotous) Polycystic Kidney Motor Neurone Disease Hunfington's Disease Parkinson's Disease Alzheimer's Disease Any OTHER disorder which runs in yout I family for which you are receiving regular | follow up or screening*** None of the above

No. of Youngest ^^ affected affected ^^

follow up or screening*** None of the above Unknown Adopted Unknown Other Unknown No contact Details

Unknown Adopted I Unknown Other

Unknown No contact Details

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

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

* ff 'Any OTHER disorder which runs in your family for which you are receiving regular follow up or screening' Pleaic give aelCiii cf ;he disorcter(!>' fc f wrrc- yoL> cxe receiving fellow uo a sc'ec-n-ng

14 Doctor's details

name Practice/clinic name and address (including postcode)

name Practice/clinic name and address (including postcode) I As Client 1

H
Telephone number

Postcode Telephone number OLP Connect 17/35

Postcode

PART 7
fcj

Medical Questionnaires

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

Medical Questionnaire 1
1 What question number, and question part (for example a, b, c) does this information relate to?

Client one
Part 2: Question ( )

Client two
Part 2: Question ( )

If you have been asked to complete a Medical Quest annaire for more than one condition, illness or njury in Part 2, you will need to complete o separate Medical Questionnaire for each one. Use this page to give details of the first condition, use Medical Questionnaire 2 oppos te for the second and then use the Additional Information section (Part 9 . or photocopy th s page, to g ve the seme details for any further condition(s)

illness or injury jf growth or lump,

|]
yea,, month,
'

How long ago did the condition first occur? How often do you have symptoms? Please tick appropriate box - do not enter anything else in the box How long ago was your iast major attack? This means a sudden increase in the seventy of symptoms, or need for treatment other than your usual medicine or tablets In the last 5 years, have you had surgery or an operation, or any other hospital admission (including an overnight stay) for this condition?

years

months

No,ymptomsno w Monthly Weekly

Yearly Daily

No symptoms now Monthly Weekly

Yeaily Daily

Never hod a major attack Other

Current y or at present years months

Never had a major attack Other

Curren y or at p ye
m nthS

Surgery 01 operation If 'Yes', how long ago? Other hospital admission (including overnight stay) If 'Yes', how long ago?

Yes years I Ies ] years

No months
No

Surgery or opera! on
1

Yes

No 1

j H 'Yes', how long ago? | Other hospital admission (including overnight stay)

years
Yes

months
No

months

In the last 5 years, in total, how much time off your normal work or daily activities have you had for this

weeks f you haven't taken time off, please enter '0' years

days

week,

days

ago was the most recent occasion? Not apolicable if you have answered '0' to question 7 above 9 Do you expect to have, or are you currently waiting for, surgery or an operation, any other hospital admission (including an oyernight stay) or referral to a specialist for this condition?

months

years

month,

f you are currently off work, please enter '0'

Surgery or operat on If -Yes', when? Other hospital admission (including overnight stay)

Yes

No

Surgery or operat on If 'Yes', when?

Yes

I. ,

No

Other hospital admission (including overnight stay)

Yes

No

10 Are you currently receiving treatment for this condition?

Yes

No

Yes

No

If 'Yes', please g ve the name of medicine or tablet, or details of other treatment, for ex ample physiotherapy. 1 more than one treatment, please state them all

11 Do you have any more medical conditions to disclose as a result of answering 'Yes' to a question in
Part 2?

Tes, p|ease corTlptete the second Medical Q ft 'Yes', please complete the second Medical 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 the remaining medical questions.

Medical Questionnaire 2
1 What question number, and question part (for example a, b, c) does this information relate to?

Client one
| Part 2: Question f

Use this page to give details of a second condition ind then use the Additional Inforrr o-- photocopy this poge. to give the same details for any further medical condition(s)

Nome of actual medical conditioi illness or injury If growth or lump.

How long ago did the condition first occur? How often do you have symptoms? "lease tick cppropr a'e box - do not enter anything else in the box I Monthly r^~s
mDt

attack? This means a sudden increase in the severity of symptoms, or need for treatment other than your usual medicine or tablets In the last 5 years, have you had surgery or an operation, or any an overnight stay) for this condition?

ver had

Surgery ot operation !' Other hospital admission (including overnight stay) ll'YW.howlonoago?

Yes

No

Surgery or operation

Yes

No

Yes

No

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

Yes

No
monlhs

yec rs

months

yec "

In the last 5 years, in total, how daily activities have you had for this If you haven't taken time off. please entei If you have had time off, how long ago was the most recent occasion? Not cpolicable 'f you hove cnswereo 0 to que^on , coove |f yi

Do you expect to have, or are you currently waiting for surgery or an operation, any other hospital stay) or referral to a specialist for

Surgery or operation If 'Yes', when? Other hospital admission (including overnight stay) If 'Yes', when? Referral lo a specialist II 'Yes', when?

Yes

No

Surgery or operation If 'Yes', when?

Yes

NO

E
Yes

Other hospital admission (including overnight stay)

No

N0

If 'Yes', when? Referral to a specialist If 'Yes', when? Yes

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 medical conditions to disclose as a result ot answering 'Yes1 to a question in Part 2?

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

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

Please now return to Part 2 and complete the remaining medical question!

OLP Connect 27/35

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 information you give will form the basis of your contract with Legal & General. If you have passed a half birthday while the application is being processed, the terms may differ from those originally quoted. In most instances the payments will be as originally quoted. Legal 8. General may sometimes offer revised terms and/or premiums and very occasionally may not be able to offer the benefits requested, legal 8. General will inform you as soon as possible if this is the case. Please remember that all items of information asked for In this application are material facts which are taken into account when assessing acceptance of the application and in calculating the premium. Please also remember that if you do not answer the questions truthfully and accurately it will very likely mean that a claim will be declined and the policy(tes) cancelled. If you are not sure if any information is relevant, please disclose it anyway. If you have given information to Legal & General in the past, please disclose it again. If necessary, please return to the questions and amend your answer in the appropriate place. Legal & General will try to rely on the information you provide and you must not assume that they will always clarify that information with your doctor (GP). However, as part of their administrative procedures, Legal & General may ask for a report from your GP to check medical disclosures. Legal 8. General may ask you to contact your doctor if they are waiting for reports which they have asked for. If Legal 8. General asks you to attend a medical examination, it may be necessary to share the application Information with another company which they have authorised. If so, that company will make the arrangements for the examination to fake place.

AB Clients-;f is mipofiwif mar yo-jrec^anoaccep/ait of Fhefoi'OA'inacaraa'-ODni, If vOu ars ' n;,- r<? of r-,n-.-Hnc c - have
For all applicants Data Protection Use of personal information: Legal , Genert I/We understand that Legal & General will us

i 'hat ( clain
I/We agree to immediately inform Legal & General In writing of any changes to the following answers on the application that 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 being declared void and the benefits due under ihe policy not being paid. I/We agree to Legal . General getting relevant information from another this box ii you DO w | 1 Client two I. Providing me/L

chtai

sharing it with a reinsurer and/or third party administrator. See also the paragraph headed 'Sensitive data'. I/We understand that Insurers share information with each other to prevent fraudulent claims via a Register of Claims and that a list of participants is available on request. The information I/we supply in this application, together information in I'ne event of a claim, will be given to the Register and m available to other participants. I/We agree that if the policy is to he set up as joint lives, i' will be own? I/We confirm that I/we have received and read the Key Features for tni product. I/We understand the features and risks of Ihe producl and are applied for, tnis applies to all). For Income Protection Benefit ortly Definition of earnings You should only cover earnings and benefits that you will you are unable to work. Employed - earnings ate defined as your annual pre tax e assessment purposes and can Include your PI Id benefits. longer receive If nings for PAYE (b) send me/us marketing information about their products and services and products ana services ot companies In the Legal E. Geneial grot;p and ot third parties whose products and services Legal , General offers to its clients. Ry signing this Declaration I/we agree to receive the information as described in (bj obove by post or telephone, unless I/we indicate othe'wise by writing with my/our lull caniacl details to Legal 5, Genera! Assurance Sociely. PO Box 274, Bangor, BTI9 7WZ. Access: I/We understand that I/we have the right to ask for a copy of my/our information please write to Legal & General at UKSO Business Standards. Legal S General Assurance Society, Brunei House, Cardiff, CF24 OEB. Approaching fraud prevention agencies: Legal & General will chec my/o details, with fruud prevention agencies. If ialse or inaccurate inform provided and fraud is identified details will be passed to fraud pre

Self employed - earnings are defined qs your share of annual pre tax profit. This means your share of the total Income from the business, less the expenses from running thai business as permitted by the HMRC guidelines. Please refer to your Key Features Document for full Information. I understand that my monthly benefit can't be mare than 60% of the first 30,000 of my pre-incapacity earnings and 50% of my pre-incapacity earnings over 30,000, up to a maximum of 16,667 per month, I understand that if, at the time of a claim, the level of benefit stated in rny policy exceeds this
ium I understand that i! I have applied for Housepersans cover, the maximum monthly benefit is 1.667 per month.

s f o r c edit jnts i managing credit anc recovering debl; checking details on proposals and claims tor all types of insurance; cnecking details of job applicants and employees.

OLP Connect 31/35

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

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 other history ofdegenerative (gradually worsening) diseases; - tnusculoskeleial disease or injury, for example arthritis, rheumatism,

jhcaTion, solely for the purposes o! alloivin n collected via this appl'cation) may be

psychosis (a mental disorder where you lose contact with reality), stress - suicidal thought; or aitempfs at suicide; o' - conditions related to drug or alcohol misuse, or smoking, or chewing tobacco. - details of 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 you have told your doctor about. negative tests for HIV. hepatitis 6 or C,

I/We have been told that Legal & Gem policy documentation. I/W<= have been told that the contract and Wales. I/We understand that the full terms and Access to Medical Reports: Notice of your Statutory Rights under the Access to Medical Reports Act 1988, the Access to Personal Files and Medical Reports {Northern Ireland] Order 1991, and the isle of Man Arcess to Health Records ana Reports Act 1993. Before they can ask any doctor that you have consulted to fii! in r: repon they need 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 lo see the reporl before the doctor returns it, in which case please tick the box below, right. It you do this the doctor can see that you require access and keep Ihe report for 21 days so that you can arranae to see it. If you have not made arrangements to see the report within this time the doctor will send the Deport to Legal & General, If you choose not to see the report at this stage you may ask the doctor for of 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 you may ask the doctor to amend it. If the doctor refuses to mate the

Legal 8. General:

setting premiums at standard rales.

to the process of getting, assessing or storing medca information, please medical informati write to: Claims and Underwriting Director, Legal 8. Genera! Ass Limited, City Park. The Droveway, Hove BN3 7PY. Medical Co ent: If Legal . General decide they need to obtain a report

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

The doctor can withhold access to the report if he or she feels 'hat it would The medical reporl your doctor fills in asks about the following: your current health - the results of referrals or tests you are waiting for

V. Legal &. General need to obtain a report frym my/our doctor: I/We do not want to see the reporl before it is sent to Legal & General Client one Q Client two j^j I/We do 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 When assessing acceptance of 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 Information ot If you believe that there U any other Information which may be relevant, please return to the questions and answer in the appropriate place. If you have given Information to Legal 8. General in the past please disclose it again. I/We confirm that I/we accept this Declaration and Consent, my/our rights under the Access to Medical Reports Act, and the notes section at the beginning of this form. By signing this Declaration I/we agree to all of the contents.

Client one

Client two

OLP Connect 32/35

PA RT 11

Direct debit instruction

This direct debit instruction must be fully completed, signed and dated before your application can be processed.

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&A Cieneral

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Instruction to your bank or building society to pay direct debits

Originator'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 ]

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1 1 1

Name and full postal address of your bank or building society branch

To: Address Postcode

Bank or Building Society

2 3

Bank account name Bank or building society account number Branch sort code

! 1 |-f | | - | |

5 i

Reference number Preferred collection date each

Instruction to your bank or building society

'lease pay Legal 8, General Assurance Society Limited direct debits from the account detailed in this nstruction 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 will be passed electronically to my bank or building society. Signature and date | Signature and date

Banks and building societies may not accept direct debit instructions for some types of account

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If you want to pay for another product(s) by direct debit from a different bank account(s), please complete another direct debit instruction for each bank account(s). Otherwise, this is all the information we need, please now cut off the Direct Debit Guarantee below and keep it somewhere safe. Use the

Cut off here and keep the Direct Debit Guarantee somewhere safe

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

^DIRECT FDebit

General

If there are any changes to the amount, date or frequency of your Direct Debit, Legal 8, General Assurance Society Ltd will notify you five working days in advance of your account being debited or as otherwise agreed. If you request Legal & General Assurance Society Ltd to collect a payment, confirmation ot the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit by Legal 3. Genera! Assurance Society Ltd or your bank or building society, you are entitled to a lull and immediate refund of the amount paid from your bank or building society - If you receive a refund you are not entitled to, 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 also notify us. OLP Connect 33/35