Income Protection Application - Step 2

To complete the application process we require your address and answers to a number of health questions. You will receive a confirmation email and a letter in the post within 14 days of your application.

Consent to process health data

I give consent to the processing of data regarding my health.*

I give consent to the processing of data regarding my health.

N.B. If you do not give consent we will not be able to progress your application any further, as your data is essential to establishing the cost of cover, any exclusions, and whether we can offer cover at all.

Application

Answering the following questions will help us ensure the product is appropriate for you. If you are in any doubt as to whether Income Protection is appropriate for you, please call Metfriendly on 01689 891454 or email [email protected]

Are you currently a salaried officer or staff of a police service in England or Wales?*

Yes
No

Are you aged between 18 and 49?*

Yes
No

Do you require a monthly benefit to be paid if you are unable to work due to incapacity or are medically retired (on physical grounds)?*

Yes
No

Do you hold an Income Protection policy elsewhere?*

Yes
No

Are you currently on restricted or recuperative duties?*

Yes
No

Key Features

You should read the key features for this product before applying. A copy of the key features will be sent to you along with a record of your application for you to sign and return.

I confirm that I have read the Key Features

Special Promotion

Promo Code (If applicable)

If you have a promo code to quote please enter it here.

Terms and Conditions

I accept the Terms and Conditions

Where did you see this promotion advertised?*

Email
Social Media (Facebook or Twitter)
Letter or Flyer
MetOffers or My Lifestyle
Metfriendly representative
Aware / Police Intranet
On this website
Other

Referral

Qualification

Officer or Police Staff*

I am aged under 50 serving as an Officer in a police service in England and Wales.
I am aged under 50 serving as Police Staff in a police service in England and Wales.

Your Details

Initial Monthly Premium

Warrant or Pay Number*

Constabulary*

Title*

Mr
Mrs
Ms
Miss

Forename*

Surname*

Date of Birth*

Gender*

Male
Female

Preferred Email Address*

Smoker*

Yes
No

Post Code*

Address Line 1*

Address Line 2

Town/City*

County

Daytime Telephone/Mobile*

Last Promotion Date*

Nationality*

Country of Birth*

Salary Details

Basic Monthly Pensionable Salary*

Monthly London Weighting

Monthly Competency Related Pay

Medical Questions

How many cigarettes do you smoke each day?*

Do you smoke any other forms of tobacco?*

Yes
No

If yes, then how much each day?*

Height*

Weight*

1. Do you drink more than 30 units of alcohol each week or have you ever regularly done so? (e.g. 1 glass of wine (175ml) = 2 units, 1 pint of lager/beer = 2 units, 1 measure spirits (25ml = 1 unit)*

Yes
No

2. Have you ever taken any drugs for recreational purposes? (e.g. cocaine, cannabis, heroin, anabolic steroids)*

Yes
No

3. Are you currently a member of the Reserve Forces (including the TA)?*

Yes
No

4. Do you engage or have you any intention of engaging in any hazardous sport or pastime? (e.g. private flying, base jumping, mountaineering)*

Yes
No

5. During the last 5 years have you ever been absent from work due to an injury or illness for a period exceeding 5 consecutive days?*

Yes
No

6. Are you currently on restricted or recuperative duties?*

Yes
No

7a. Do you hold any other policies covering incapacity due to accident or illness except those taken out to cover a loan?*

Yes
No

7b. Are you presently applying, or during the last 2 years have you applied, for Income Protection or Critical Illness Insurance with any other provider or have you had a policy that has been rated or declined?*

Yes
No

8. Have you ever tested positive for HIV / AIDS, Hepatitis B or C or been tested or treated for any other sexually transmitted disease or are you awaiting the results of such a test?*

Yes
No

9. Have you ever sought, or are you currently seeking or intending to seek, medical advice for:

9a. Any disease or disorder of the heart or circulatory system including raised blood pressure?*

Yes
No

9b. Stroke, transient ischaemic attack or any form of haemorrhage?*

Yes
No

9c. Cancer (including leukaemia, lymphoma and Hodgkin's disease) or any mole or skin marking that has bled, changed or become painful or any form of tumour or lump?*

Yes
No

9d. Diabetes, sugar in the urine or raised cholesterol?*

Yes
No

9e. Any disease or disorder of the blood?*

Yes
No

9f. Multiple Sclerosis, Parkinson's disease, Alzheimer's disease, Motor Neurone disease, optic neuritis, numbness, paralysis, loss of feeling, blurred or double vision or any hereditary disorder?*

Yes
No

10. Before the age of 60 have either of your parents, brothers or sisters (including half brothers or half sisters) ever suffered from heart or circulatory disease (including heart attack or angina), cancer, stroke, high blood pressure, "diabetes, paralysis, a disorder of the nervous system, eye disease, familial polyposis of the colon, Huntington's disease, "Motor Neurone disease, kidney disease or any hereditary disease?"*

Yes
No

11. During the past 5 years have you suffered from any illness or injury requiring investigation, consultation, treatment, tests (including blood tests) or advice by a specialist, clinic, hospital or doctor?*

Yes
No

12. Do you have any current symptoms or complaint for which you have not sought medical advice but intend to (you do not need to disclose matters relating to uncomplicated pregnancy, fertility treatment, hay fever, common colds and flu or vaccinations)?*

Yes
No

13. During the past 5 years have you suffered from any illness or injury requiring investigation, consultation, treatment, tests (including blood tests) or advice by a specialist, clinic, hospital or doctor?

13a. Epilepsy, fits or blackouts?*

Yes
No

13b. Mental illness, anxiety, stress, post traumatic stress disorder, depression or any other psychiatric or nervous disorder?*

Yes
No

13c. Arthritis, rheumatism, gout or trouble with your bones, joints or muscles?*

Yes
No

13d. Asthma, bronchitis, pneumonia or other respiratory disorder?*

Yes
No

13e. Any disorder of the stomach, digestive system, liver or bowel?*

Yes
No

13f. Any kidney or bladder disorder?*

Yes
No

13g. Any gynaecological disorder or abnormality of the breast, uterus or cervix?*

Yes
No

13h. Any form of allergy, skin complaint or any problem with sight or hearing?*

Yes
No

14. In the last month, have you

14a. tested positive for Coronavirus (COVID 19)?*

Yes
No

14b. been tested for Coronavirus (COVID 19) but have not yet received a result?*

Yes
No

14c. been personally advised to self-isolate by a medical professional or the national advice centres (e.g. NHS 111) but have not been diagnosed with Coronavirus (COVID 19) and are still self-isolating?*

Yes
No

14d. had direct contact with someone who’s been confirmed or is still suspected to have Coronavirus (COVID 19)?*

Yes
No

15. Do you currently have symptoms such as a persistent cough, high fever, fatigue or body aches?*

Yes
No

If you have answered YES to any of the questions on the previous pages, please use this space to provide details. Use the questions shown to provide your answers.

Which question(s) does the information relate to?
What medical condition have you been diagnosed with?
What symptoms have you suffered with?
When did you first suffer symptoms?
When did you last suffer symptoms?
Have your symptoms been continuous?
Are you receiving any treatment; if yes what treatment?
Have you had any time off work?
If yes, how much time off work?
Are you fully recovered?

Confirming Your Identity

In order to process your application Metfriendly will refer to Credit Reference Agencies to confirm your identify. This search will leave a ‘footprint’ on your credit file, which is required to record that the check has taken place. This footprint is not the same as a credit check footprint and has no negative impact on your file. Please read the following:

I understand that you will undertake a search with a Credit Reference Agency for the purposes of verifying my identity. To do so the Credit Reference Agency may check the details I supply against any particulars on any database (public or otherwise) to which they have access. They may also use my details in the future to assist other companies for verification purposes. A record of the search will be retained. Your information may be disclosed to a credit reference agency, which may keep a record of that information; and (b) the credit reference agency may disclose that information, and the fact that a search was made, to its other customers for the purposes of assessing the risk of giving credit and occasionally to prevent fraud, money laundering and to trace debtors.

Hidden

ID Declaration*

I understand that you will undertake a search with a Credit Reference Agency for the purposes of verifying my identity. To do so the Credit Reference Agency may check the details I supply against any particulars on any database (public or otherwise) to which they have access. They may also use my details in the future to assist other companies for verification purposes. A record of the search will be retained. Your information may be disclosed to a credit reference agency, which may keep a record of that information; and (b) the credit reference agency may disclose that information, and the fact that a search was made, to its other customers for the purposes of assessing the risk of giving credit and occasionally to prevent fraud, money laundering and to trace debtors.

I agree to a search with a Credit Reference Agency to verify my identity
I do NOT agree to a search with a Credit Reference Agency and will supply Metfriendly with paper based ID

Declaration

Please note, when making the declaration below, all relevant facts should be disclosed, even if you are unsure whether they are material to this insurance. Failure to do this may result in the insurance cover being ineffective, even if the proposal has been accepted by the insurer. Do not assume that we will obtain a report from your Doctor. We rely on you to disclose all relevant information. A copy of the terms and conditions of the proposed insurance contract and also a copy of the completed proposal form is available on request.

Declaration

Please read this carefully: I declare that the foregoing statements are to the best of my knowledge and belief true and complete. I agree to abide by the Rules of the Society. I authorise the deduction from my salary of all contributions that may become due. I authorise extra premiums (where required) from my first deduction to ensure my policy starts on my preferred start date. The liability of the society does not begin until the application has been accepted. Any medical condition that arises prior to the startdate must be notified to the Society or your claim may be denied.

I declare that the statements above are true

Optional Questions

How did you hear about Metfriendly?

...please state*

Would you be interested in receiving news about any of the following?

A personal consultation with a Metfriendly Representative
Lifetime ISA (Available to under 40s only)
Critical illness/protection/life cover
Saving regularly
Investing a Lump Sum
Savings products for younger children/relatives
Attending a retirement seminar
Guidance of preparing for retirement/change of career

What prompted you to take out this product at this time?

What was the main reason you chose Metfriendly?

Further Detail

Income Protection Application – Step 2