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C : COURTAGE
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Loan insurance
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new
Lnl Solution
Special risks
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For borrowers with insurance problems
Quotation request - 2005/2006
Subscription possible up to age 70 f o r Death cover M a xi mum Capital insured in PTD/TTIW: 310,000 "Bonus" ser v i c e s : removal, works and Remote monitoring Pe r s o n a l i z e d quotation for: increased-risk illnesses, dangerous professions and high risk sports Capital from 15,000 to 1,220,000
assurances
Reserved for APRIL Assurances
Lnl Solution
Loan insurance special risks
PRE 4101
Quotation request
000E0F4B
insurance consultant no. Fax sent (date) subscrib er no. Are you already insured with APRIL Assurances YES NO PLEASE COMPLETE THIS SUBSCRIPTION APPLICATION IN BLOCK CAPITALS Subscriber Company Private
Stamp and signature of insurance consultant
C: COURTAGE 17 Villa du Petit Parc 94000 CRETEIL Tél. : 01 45 17 68 68
Company name/Name: ............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ A ddress: .................................................................................................................................................................................................................................................................................... Post code: Town: ....................................................................................................................................................................................
INSURED 1
Mr
Mrs
Ms
Name: .......................................................................................................................................................................................................................... First name: ................................................................................................................................................................................ Date of birth So cial Security subdivision: So cial Security Self-Employed Agricultural Other: ...................................................................................................................... Status*: Executive Executive category Non-executive Profession Artisan Trader Farmer Exact profession: .................................................................................................................................................................................. A ctivity sector: ........................................................................................................................................ Employer: .......................................................................................................................... No. of business km/year (excluding journey between home and work): 15 000 km/year + 15 000 km/year Work abroad: if yes, Country: ................................................................ Do you regularly handle loads in your work ? Yes No Frequency of trips abroad: ............................................................................ Do you work at a height of over 15 metres? Yes No Work contract: Permanent work contract Fixed term contract Temporar y worker Seasonal worker <1/2 time Suspension of work contract; reason: ................................................................................
Shared information Planned date of removal: Present address: ................................................................................................................................................................................................................................................ Post Code E-mail: ........................................................................................................................................................................................................................................................................................ Phone (home) Future address: .................................................................................................................................................................................................................................................... Post Code Loan characteristics
Insurance start date (Date of signing loan offer): Loan amount
...................................................................................................................................................................
Town: Town:
..........................................................................................................................................................................
M obile
..........................................................................................................................................................................
Date of 1st repayment: Total duration of loan (including deferred amortization or pre-payment period) Interest rate
....................................................
Rate type Fixed Variable
Euros
.........................................................................
M onth(s) Interest-only
%
Typ e of loan:
Classic Zero-interest loan
Leasing Successive release operations
Flexible Bridging loan Other: ......................................................................................................................................
Main residence Prop erty purchase Rental investment Personal loan Professional investment Other: .............................................................................................................................................................................................................................................................................................................................................. If frequency other than monthly, please: ........................................................................................................................................................................................................................................................................................................................................................................................................................................................................ Deferred amortization or pre-payment period: Yes No Number of months: Are the loan repayments constant throughout the deferred period? Yes No (if no, TTIW/PTD impossible for interest-only loans and loans with deferred amortization between 6 and 24 months) Lending organisation: Name: ................................................................................................................................................................ A ddress: ................................................................................................................................................................................................................................................................ Post Code: Town: ............................................................................................................................................................................................................................ Phone : Fax : If the delegation of benefit is to be sent to another address (branch or registered office), give details: ........................................................................................................................................................................................................................ A ddress: .................................................................................................................................................................................................................................................................................. Post Code: Town: .................................................................................................................................................................... Fax: Phone: If the beneficiary is not the lender, please send us the bank's written agreement and specify the beneficiary clause (e.g. available on Intrapril):..................................................
..............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Purp ose of loan:
Characteristics of insurance Insured
Death/TILA coverage rate(1) Loan cover
..........................................................................
(DC)
TTIW/PTD coverage rate(2)
..........................................................................
(AT)
%
%
Payment by direct debit
Frequency: monthly quarterly six-monthly annual Payment charge: e2.29 per payment Indicate the day of the month for debiting your premium, between 1st and 10th. . Ser vice charges: e45.73 I enclose a cheque in advance payment for the amount of (minimum e45) .......................................... e made out to APRIL Assurances.
I apply for subscription to the APRIL Assurances "Association des Assurés" and its subscribed agreement with Axeria for loan insurance cover. "I declare that I have been informed of the statutes and internal regulations of the APRIL Assurances "Association des Assurés". I declare that I have been informed of the general terms serving as information notice, reference PREA 05-08/05, for my cover as attached to this subscription application, and in particular of my right to withdrawal, that I accept their provisions and have kept a copy of them, together with the terms applicable to APRIL Assurances management operations. Within the framework of modification of my contract by means of an additional clause, I note that the general terms applicable are those of which I was informed on signature of the initial subscription application and referenced above. I confirm that I have been informed that the information collected is necessary for the assessment and processing of my subscription application, and that the administrative information is subject to computer processing by APRIL A ssurances and the Insurer, or their authorised agent, for requirements associated with execution of my subscription to the contract. In accordance with the law of 6 January 1978 (modified), I have the right to access and, if necessary, rectify any information concerning me held in these files by writing to APRIL Assurances - 27 rue Maurice Flandin, 69003 Lyon. APRIL Assurances may use certain administrative information and communicate this information to its partners, a list of which will be sent to me on request, in order to enable them to offer me new products or services. In accordance with the law of 6 January 1978 (modified), I can oppose such communication by simply writing to APRIL Assurances (at the above address), and the postage cost will be refunded to me. I declare that I have been informed that my phone communications with April Assurances offices may be recorded for internal management purposes. I may obtain access to the records concerning me by sending a letter to the following address: APRIL Assurances, 27 rue Maurice Flandin, BP 3261, 69403 LYON CEDEX 03, it being understood that each record is kept for a maximum period of two months. I, the undersigned, declare that I have answered the questions asked exactly and sincerely, and that I have not declared anything or omitted to declare anything that could mislead the April Assurances "Association des Assurés" Insurer.
Signed in: Date 02 quotation request Signature of Subscriber preceded by the wording "read and approved" Signature of Insured preceded by the wording "read and approved"
Lnl Solution
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Loan insurance special risks
Health questionnaire increased risks
You must answer all these questions yourself, as exactly as possible, since your statements are legally binding. This health questionnaire is essential for assessment of the risk that the insurer intends to cover. Failure to reply to one of the questions will give rise to additional requests. The medical information you communicate is covered by professional confidentiality. By giving us as much information as possible, you will help us to give you an answer as soon as possible. In order to keep this questionnaire confidential, please send it in a sealed envelope to the APRIL Assurances Medical Examiner.
)
Insured
Name: ........................................................................................ First name: ................................................................................ Weight: ...................................... in kg Height: ................................................ in cm Blood pressure:
yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes no no no no no no no no no no no no no no no no no no no no no no no no no no no no no no Reason? .......................................................................................................................................................................................................................................................................................................................... Start date End date Reason? .............................................................................................................................................................................................................................................................................................................................. Type: ...................................................................................................................................................................................................................................................................................................................................... After-effects: .......................................................................................................................................................................................................................................................................................................... Type: ........................................................................................................................................................................................................................................................................................................................................ Duration: .......................................................................................................................................................................................................................................................................................................................... Type: ............................................................................................................................ After-effects? .................................................................................................................................................... In the case of sight problems: visual acuity after correction:: Left eye: ...................... Right eye: ........................ Rate? ........................................................................................................................................................................................................................................................................................................................................ What? .................................................................................................................................................................................. Date After-effects: .............................................................................................................................................................................................................................................................................................................. What was the result: .......................................................................................................................... Date Treatment? .................................................................................................................................. Since when? Date ? Date ? What: ................................................................................................................................................................ Treatment: .................................................................................................................................... Since when? What?.................................................................................................................................................................................. Date? What? ...................................................................................................................................................................................................................................................................................................................................... What? ...................................................................................................................................................................................................................................................................................................................................... Date? Location: .................................................................................................................................................... What?: .............................................................................................................................................................................. Date? Date ? Treatment: .................................................................................................................................................................................................................................................................................................................. Location: ............................................................................................................................................................................................................................................................................................................................ IDD NIDD Treatment:: .............................................................................................................................................................................................................................. Rate: ........................................................................................................................................ Treatment: .................................................................................................................................................. Numbers of crises/year: .......................................................... Treatment: .................................................................................................................................................. Location: ........................................................................................................ Date of appearance? Type: .................................................................................................................................... Location: .......................................................................................................................................................... What? .................................................................................................................................................................................................................................................................................................................................... Type: ........................................................................................................................................................................................................................................................................................................................................ Classification: ...................................................................................................................................................................................................................................................................................................... Classification: ............................................................................ End date of treatment? Treatment: .................................................................................................................................................................................................................................................................................................................. Type: .................................................................................................................................................................................... Date? Treatment: .................................................................................................................................................................................................................................................................................................................. Type: .................................................................................................................................................................................... Date? What? ...................................................................................................................................................................................................................................................................................................................................... If yes, daily quantity:.................................................................................................................................................................................................................................................. litre(s) If yes, daily quantity: .............................................................................................................................................................................................................................. cigarette(s) Date of last examination? Result: ...................................................................................... Date of last examination? Date of last examination? Result: ...................................................................................... Result: ......................................................................................
Are you currently on sick leave, or have you been on sick leave for over 15 days in the past three years? Are you 100% covered for a long term illness, or is an application for 100% cover in progress? Have you been hospitalized for over 10 days in the past ten years, or are you due to undergo a surgical operation? Have you been hospitalized for convalescence, treatment or re-education or stayed in a spa during the last five years? Do you suffer from a congenital malformation or disability? Sight or hearing problems? Do you receive a disability allowance (even partial) or is an application in progress? Have you been the victim of an accidental bodily injury? Have you had a seropositivity screening test - HIV test? Do you suffer from, or have you suffered from, any of the following illnesses: Hypertension Infarct Cardiovascular disease Respiratory disease, asthma, chronic bronchitis Kidney disease (kidney stones, blood in the urine) Genitourinary disease Disease of the digestive system Ulcer Disease of the nervous system Neuropsychic disorder Epilepsy Paralysis Endocrine disorders (diabetes, thyroid) Metabolic disease (cholesterol, etc.) Gout Arthritis, rheumatism Diseases of the bones, joints or ligaments Back problems, herniated disk, lumbago, etc.? Cysts operated on Tumours Cancer Disease of the immune system (AIDS) liver disease (Hepatitis C) Have you had any other illnesses not listed above? Have you received specialist treatment such as radiation or chemotherapy? Are you currently receiving medical treatment? Do you drink alcohol daily? Are you a smoker? Have you had a blood or urine test? Have you had an X-ray examination? Have you had an electrocardiogram? Have you had an electroencephalogram, scan, RMI or other examination? Do you currently hold any life or disablement insurance contracts (capital or income)?
Signed in: Date 03 quotation request
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no no no no no no no no no no
Date of last examination? Result: ...................................................................................... Amount covered: ................................................................................................................................................................................................................................................................ euros Effective date: Maturity date:
Signature of Insured
Copy for INSURED
Professional questionnaire
In the case of professional risk, please complete the entire health questionnaire.
For documents to be enclosed, se please see the rever of this page
Name: .................................................................................................... First name: .................................................................... Age: ............................
1 2 3 4 5 6 7 8 9
What is your job title?
................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
What sector do you work in?
Please describe your tasks: a) ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
b) ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
What is your workplace (in an office, outside, in a factory, etc.)? What machines do you operate?
..........................................................................................................................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Are you exposed to difficult working conditions (dust, radiation, asbestos, etc.)? yes no If so, please provide full information ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Do you need a licence or specific permit to perform your work (such as a driving licence, etc.) or a certificate of capability?
yes
no
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
Do your work activities include: yes no - works in port areas, at sea, underground, at a height or on pylons? If so, give details: ...................................................................................................................................................................................................................................................... - handling toxic products, explosives, firearms? If so, give details:.............................................................................................................................................................................................................................................................................................................................................. Do you travel expenses in the course of your work? If so, indicate: a) How many kilometres do you travel per week? .................................................................................................................................................................................................................................................................................................................................................................................................... b) Your transport method .................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................. c) Do you travel outside France? yes no if yes, how much time do you spend abroad each year? ................................................................................................................................................................................................................................................................................................................................................................................
Signed in:
Signature of Insured
Sports questionnaire
1 2
Date
In the case of sports risk, please complete the entire health questionnaire.
What sport(s) do you practise? Do you practise competitive sports? oui Which .................................................................................................................................................................................................................................................................................. non If so, at what level: (national, international, etc.)............................................................................................................ Frequency: ..............................................................................................................................................................................................................................................................
Signature of Insured
Signed in: Date
Direct debit authorisation
I authorise the establishment holding my account to debit the account, if its situation allows, with all debit amounts specified by the creditor shown opp osite. In the case of a dispute on the debit amount I will be able to susp end execution by simple request to the establishment holding my account. I will settle the dispute directly with the creditor.
Creditor: APRIL Assurances national issuer no.: 142 662 27 rue Maurice Flandin - BP 3261 - 69403 LYON CEDEX 03
Codes Establishment Branch no.
Account to be debited
A ccount no Check code
A compléter obligatoirement
Mandator y Debtor
Establishment holding account to be debited Name: ...................................................................................................................................................................................................................................................................... A dress: ....................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................................................................................
Name: .................................................................................................................................................................................................................................. First name:.................................................................................................................................................................................................................... A dress: .................................................................................................................................................................................................................................... Post Code: Signature: Town:...................................................................................... Date:
Post Code:
Town:
............................................................................................................................................................
creditor, I send this form to the ice account off hing a bank or post - mandatory) attac B or RIP identification slip (RI the back) (stapled to
04
quotation request
I enclose
· My subscription application: completed, dated and signed · My direct debit authorisation: completed and signed · My bank or post office account identification slip · My cheque for the advance payment: made out to APRIL Assurances · Supporting medical documentation, etc.
And after subscription?
Your subscription application is processed as soon as it is received by APRIL Assurances. Cover takes effect at the earliest the day after the date of receipt, subject to payment of the first premium. In the days following signature of your contract, your insurance consultant will give you your insurance documentation comprising:
(
important
· The insured person's guide (practical information) · Your card with your insurance number · Your subscription certificate · Your payment schedule (situation of your account)
)
See the back of this sheet for direct debit authorisation to be completed and signed.
05
quotation request
A P R I L A s s u r a n c e s b y yo u r s i d e
APRIL Assurances designs, manages and distributes simple and innovative insurance solutions, manages them with constant emphasis on reactivity and quality, and distributes them via a network of independent insurance consultants. With ISO 9001 version 2000 certification for its personal insurance design and management activities, APRIL Assurances puts customer satisfaction at the heart of its commitments.
A wide range of solutions
Highly diversified, they enable APRIL Assurances to offer a response to the widest possible range of insurance requirements : family, employees, borrowers, seniors, directors, the self-employed, students, travellers.
Providence Health insurance and individual providence solutions.
Phone
Loan insurance and credit offer solutions.
Phone
Health insurance and providence solutions for companies, protection for company directors.
Phone
0 891 46 9000
0,23inc . VAT/min
0 891 46 6000
0,23inc . VAT/min
04 72 36 75 35
· Immediate processing of documentation for management within amaximum 24 hours. · 94% of people insured are satisfied with APRIL Assurances* products and services, · 96% of our insurance consultants would recommend APRIL Assurances to a colleague**.
In 2005 APRIL Assurances entres Top 25 companies "Best places to work" in France.
APRIL Assurances subsidiaries
Saving, retirement and defiscalization solutions.
International insurance solutions.
Automobile and home insurance solutions.
Key facts
· APRIL Assurances founded in 1988, · Division of APRIL GROUP, listed on the "Second Marché" of the Paris bourse, · Almost 1 million people insured individually or through their employers, · 550 staff, · 1 ,400 independent insurance consultants. 1
Your Insurance Consultant
C: COURTAGE 17 Villa du Petit Parc 94000 CRETEIL Tél. : 01 45 17 68 68
assurances
Registered office, 27 rue Maurice Flandin - BP 3261 69403 Lyon Cedex 03 Fax 04 78 53 65 18 - Internet www.april.fr
APRIL ASSURANCES IS A DIVISION OF APRIL GROUP
Insurance management and broking SA with capital of 500,000 - Registered on the ALCA list - 428 702 419 RCS Lyon. Financial and professional civil liability cover in accordance with sections L530.1 and L530.2 of the Insurance Code.
Réf. 10003< - All marks, logos, graphic layout and promotional text contained in this document are registered and the property of APRIL Assurances SA.
These elements, and text of any kind, may not be reproduced in whole or in part. Failure to comply with this rule will lead to legal action. *cumulative total of "satisfied" and "fairly satisfied" replies to an IPSOS phone survey carried out in May 2004 with a sample of 800 people insured. **ccumulative total of "would certainly recommend" and "would probably recommend" replies to an IPSOS phone survey carried out in May 2004 with a sample of 240 correspondents and October-November 2004 with a sample of 240 correspondents.