I/We declare that the information and statements provided
above are true and I/we have taken reasonable care to ensure
that my/our answers to the questions asked are correct. I/We
understand that if any information provided by me/us is
subsequently found to be inaccurate the policy may be amended
or cancelled in accordance with the Consumer Insurance
(Disclosure and Representations) Act 2012. I understand that
this may mean the benefits payable to me/ us are reduced
and in some instances the policy may be cancelled.
I/We agree that the Provider may obtain medical information
from any doctor who, at any time, has attended me/us, about
anything that affects my/our physical or mental health and/or
any insurance office to which a proposal has been made on
my/our life and I/we authorise the giving of such information.
This consent shall remain valid throughout the duration of
the insurance and after my/our death unless I/we advise the
Provider otherwise.
I/We agree that the Provider may apply for medical evidence.
I/We authorise the Provider to pass medical information to
any medical officer on the Provider’s behalf.
I/We accept the Provider will use the information I/we give for
administration, underwriting, claims, research and statistical
purposes. I/We agree the Provider may pass information about
my/our physical or mental health or condition to medical
practitioners and reinsurers.
I/We agree that a copy of this declaration and consent can be
treated as the original.
I/We agree to the Provider processing my/our medical data in
accordance with the Annuityhelp Direct Privacy Notice, and the
Retirement Health Form Privacy Notice
I/We understand that I/we must inform the Provider without
delay if there is a change to my/our health or circumstances
before the commencement of the policy. I/We understand
that failure to do so may result in amendment or cancellation
of the policy in accordance with the Consumer Insurance
(Disclosure and Representations) Act 2012.
I/We have been duly notified of my/our rights under the
Access to Medical Information legislation
governing access to medical records.
I/We understand that the Provider may pass the information
to third parties for the prevention or detection of fraud,
enabling assets to be rightfully claimed or where required
by law or regulation.