Free Life Insurance for New Parents Section C - Plan Details Plan type: Sum insured: Term: Free life insurance for new parents € 10,000 One year from d.o.b Section D - Medical Details Have you received any form of medical treatment for cancer in the past 12 months of the date of application, or have you been diagnosed with HIV infection, or do you work / reside outside of the Maltese Islands ? First Person Covered Second Person Covered yes yes no no I declare that the information given on this Application Form is true, accurate and complete and that no material fact has been withheld. I understand that failure to disclose a material fact may result in the contract being declared void and that a claim under the policy may not be paid. A material fact is one which is likely to influence MSV Life in the best assessment and acceptance of this Application Form. If in doubt as to whether a fact is material, then it should be disclosed. I understand that the contract will not be in force until the Application Form has been accepted by MSV Life in writing. I have received / read a copy of the ‘Information Guide’ of the product for which I am applying and understand its content. The Application Form and the Policy Document shall be the basis of the contract between myself and MSV Life. I acknowledge and accept that MSV Life may process the personal data that I provide in this Application Form in accordance with the Data Protection Act, 2001 and with the Data Protection Policy of MSV Life (a copy of which is available from MSV Life’s offices, website and Tied Insurance Intermediaries). I acknowledge that I have a right to request access to and rectification of such data as processed by MSV Life. Any such request must be signed by myself as the Policy Owner to whom the personal data relates. I do not wish to receive Direct Marketing material by E-mail on the E-mail address provided in this Application Form. Full name of Policy Owner and Person Covered Signature Full name of Joint Policy Owner and Person Covered Signature Application Date Section E - Declaration (to be completed for all applications) I declare that I am the Intermediary for this application and that the signature of the Policy Owner is authentic. I have explained the product details to the Policy Owner and also established his identity. Intermediary Rubber Stamp / Name Signature Code: D80102201 COM 180511 Registered Address: MSV Life p.l.c., Middle Sea House, Floriana, FRN 1442, Malta. Postal Address: P.O. Box 54, Marsa, MRS 1000, Malta. Registration Number: C15722 Telephone: (+356) 2590 9000 Telefax: (+356) 2122 6429 Email: [email protected]Website: www.msvlife.com MSV Life p.l.c. is authorised by the Malta Financial Services Authority to carry on long term business under the Insurance Business Act 1998. If the answer to the above is yes, then unfortunately we are unable to offer you the free life insurance.
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Free Life Insurancefor New Parents
Section C - Plan Details
Plan type: Sum insured: Term:Free life insurance for new parents € 10,000 One year from d.o.b
Section D - Medical Details
Have you received any form of medical treatment for cancer in the past 12 months of the date of application, or have you been diagnosed with HIV infection, or do you work / reside outside of the Maltese Islands ?
First Person Covered Second Person Coveredyes yesno no
I declare that the information given on this Application Form is true, accurate and complete and that no material fact has been withheld. I understand that failure to disclose a material fact may result in the contract being declared void and that a claim under the policy may not be paid. A material fact is one which is likely to influence MSV Life in the best assessment and acceptance of this Application Form. If in doubt as to whether a fact is material, then it should be disclosed. I understand that the contract will not be in force until the Application Form has been accepted by MSV Life in writing.
I have received / read a copy of the ‘Information Guide’ of the product for which I am applying and understand its content. The Application Form and the Policy Document shall be the basis of the contract between myself and MSV Life.
I acknowledge and accept that MSV Life may process the personal data that I provide in this Application Form in accordance with the Data Protection Act, 2001 and with the Data Protection Policy of MSV Life (a copy of which is available from MSV Life’s offices, website and Tied Insurance Intermediaries). I acknowledge that I have a right to request access to and rectification of such data as processed by MSV Life. Any such request must be signed by myself as the Policy Owner to whom the personal data relates. I do not wish to receive Direct Marketing material by E-mail on the E-mail address provided in this Application Form.
Full name of Policy Owner and Person Covered Signature
Full name of Joint Policy Owner and Person Covered Signature
Application Date
Section E - Declaration (to be completed for all applications)
I declare that I am the Intermediary for this application and that the signature of the Policy Owner is authentic. I have explained the product details to the Policy Owner and also established his identity.
MSV Life p.l.c. is authorised by the Malta Financial Services Authority to carry on long term business under the Insurance Business Act 1998.
If the answer to the above is yes, then unfortunately we are unable to offer you the free life insurance.
A4 Brochure D.indd 1 20/05/2011 09:57
Why are we offering free life cover to new parents?We believe life insurance and family protection are the cornerstones to successful financial planning and security. Whilst we can never replace you, our offer is designed to give your family a helpful start in replacing your income in the event of your death. The MSV Free Life Insurance for New Parents is there to help make your life that little bit easier by giving you the peace of mind you deserve.
Plan descriptionA life insurance plan that pays out €10,000 if you die on, or before, your child’s first birthday
Your commitment• Simply give us all the information we ask for in the application process and if you have to make a claim• The life cover is free to all new parents so there are no premiums to pay
Risk factors• The plan has no cash surrender value• If you do not truthfully provide all the information we ask for we may not pay out under the plan• If you stop living in Malta your plan will end
Who may apply?• You can take out the plan if you are a new parent aged 18 to 65, living in Malta• You can take out the plan once the child has been born and before they are 6 months old• The plan will be issued on the lives of both parents and will pay on the first death only• Single parents may apply, although only one policy can be issued per child
When will the plan pay out?• The plan will pay out on death of a parent before the child’s first birthday• The plan will pay out only once so for joint life plans we will only pay on the first death of a parent• The plan will end on the earliest of the child’s first birthday or once the death benefit has been paid
When will the plan not pay out?• The plan will not pay out if you commit suicide, or if you die as a result of a HIV-related illness,non-prescribed drug abuse or if it is related to or caused by a history of alcohol excess• The plan will stop once your child has passed their first birthday• Full details of the exclusions are covered in the Policy Document
When will the cover start?The cover will start once you have completed the application form and we have confirmed your plan has started
What about tax?• The cash sum paid on death is currently free from income tax and capital gains tax• Tax rules may change
Can I change my mind?The life cover is free until your child’s first birthday, however if for whatever reason you decide you do not want to proceed with the plan you can notify us in writing and we will cancel the policy.
What to do nextIf you would like any further information about the MSV Free Life Insurance for New Parents please contact MSV Life p.l.c. or any of our authorised Tied Insurance Intermediaries or call at any branch of Bank of Valletta p.l.c. or APS Bank, Malta.
Section A - Details of Policy Owner / Persons Covered (to be completed for all applications)
First Name/s
Surname / Title
Maiden Name
Marital Status /Gender
I.D. Card* / Passport
For office use ONLY
Joint Policy Owner and Person CoveredPolicy Owner and Person Covered
Male Female
Date of Birth / Country of Birth
Address
Telephone (Home)
Telephone (Mobile)
Telephone (Work)
E-mail
Occupation
Country of Residence
Country of Employment
Male Female
Postcode Postcode
Section B - Details of the Baby
Application Form
First Name/s
Surname
Gender Male Female
Date of Birth
ID Card NO
Please provide us with a true authenticated copy of the baby’s birth certificate
