Income Protection Application Form

Please Note that Irish Life’s products and the information on this application are provided for residents of the Republic of Ireland only.

Personal Details
Name, DOB and Gender
Title*
First Name*
Surname*
Date of Birth*
If your date of birth is incorrect any claim payment will be recalculated.
Gender*
Relationship Status*
Address*
Country of Birth
Country
Previous Surname (If Any)
Occupation*
Current level of earnings*
Email Address*
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Phone Number*
During the last 12 months, which of the following best describes your smoking habits:
During the last 12 months, which of the following best describes your smoking habits:*
- Smoker
- Occasional Smoker
- Used nicotine replacement or e-cigarettes
- Non Smoker
Nationality*
Are you Irish resident for tax?
Are you Irish resident for tax?*
- Yes
- No

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Medical and Other Information
Important - Telling Irish Life about material facts (See more details.)

Please remember that you must tell us everything relevant when answering all of the questions on the application form. If you do not, or if any of the answers to these questions are not true and complete, we could treat the plan as void. This includes disclosing tobacco consumption. If failure to reveal all facts occurs there will be no cover under the plan and we will not refund the payments.

In these circumstances we will not pay a claim. A material fact (relevant information) includes anything that a reputable insurer would treat as likely to influence the assessment and acceptance of an application for insurance. If you are not sure whether something is relevant, you should tell us anyway. If there is anything not covered by the questions on this form that you think we should know, please tell us in the section ‘Other medical evidence’. We may also contact you by telephone if we need to ask you for further information on your answers to the health questions or as part of any subsequent claim investigation. If we phone you these calls will be recorded.

We will rely on what you tell us and you must not assume that we will automatically clarify or confirm any information you provide. You can provide any highly confidential information directly to Irish Life’s Chief Medical Officer in a sealed envelope with your name, date of birth and application number (if applicable) and give this to your financial adviser. In these circumstances you must refer to this information when answering your health questions.

You should not tell us about any genetic test (that is, any analysis of chromosomes, DNA or RNA to detect genetic abnormalities in individuals) which you may have had. You must however, tell us if you are having treatment for or experiencing symptoms of a genetic condition. You will also be asked to give us full information about your family history, including all genetic conditions.

If your health changes between the date you apply for cover and the date your application is accepted, you must let us know immediately as failure to do this may result in a claim being refused. If for whatever reason there is more than a 6 month delay between the time your application is accepted and the date your plan starts (is issued), and your health has changed then you must also let us know immediately
1. Please give the name and address of your doctor.
Doctor's name*
Years with doctor*
Address*
If you have changed your doctor in the last year, please give the name and address of your previous doctor.
Previous Doctor's name
Previous Doctors Address
2. Please give your height and weight.
Height*
Weight*
3. Which of the following best describes your smoking habits.
*
- I am a smoker
- I am an occasional smoker or have smoked in the last 12 months
- I have used nicotine replacement products including E-cigarettes in the last 12 months
- I have not smoked or used nicotine replacement products including E-cigarettes in the last 12 months
- I am a life long non smoker
If selected ‘I am a smoker’, what do you smoke and how many / much a day?:*
4. Do you drink alcohol?
Do you drink alcohol?*
- Yes
- No
Alcohol consumption (total number of units) per week
Pint of Beer - 2.0 units, Glass of Beer - 1.0 units, Measure of Spirits - 1.0 unit, Bottle of Wine - 7.0 units, Glass of Wine - 1.0 unit
Pint of Beer - 2.0 units, Glass of Beer - 1.0 units, Measure of Spirits - 1.0 unit, Bottle of Wine - 7.0 units, Glass of Wine - 1.0 unit
5. Have you ever had treatment or advice from a health professional in relation to stopping or reducing your alcohol consumption?
Have you ever had treatment or advice from a health professional in relation to stopping or reducing your alcohol consumption?*
- Yes
- No
If YES, add details here

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Income Protection Application Form

Personal Details

Name, DOB and Gender

During the last 12 months, which of the following best describes your smoking habits:

Are you Irish resident for tax?

Income Insurance

Which Income Insurance Option do you want?

Annual amount of income you want to receive

This will be paid after how many weeks of continuous incapacity

This cover will continue until you reach age

If you have a claim, do you want your benefit to increase yearly (escalation)

Do you want inflation protection (indexation)?

Are you entitled to State Disability Benefit?

Do you currently have existing Income Insurance with Irish Life or any other Life Office?

Payment Details

Payment frequency

Medical and Other Information

Important - Telling Irish Life about material facts (See more details.)

<span class="section-blue">1.</span> Please give the name and address of your doctor.

If you have changed your doctor in the last year, please give the name and address of your previous doctor.

<span class="section-blue">2.</span> Please give your height and weight.

<span class="section-blue">3.</span> Which of the following best describes your smoking habits.

<span class="section-blue">4.</span> Do you drink alcohol?

Alcohol consumption (total number of units) per week

<span class="section-blue">5.</span> Have you ever had treatment or advice from a health professional in relation to stopping or reducing your alcohol consumption?

Medical and Other Information Continued.

<span class="section-blue">6.</span> Have you ever had diabetes (type 1 or 2 or pregnancy related) or sugar in the urine?

<span class="section-blue">7.</span> Have you ever had any disease or disorder of the heart, including angina, heart attack, bypass, cardiomyopathy, heart valve disorder or heart murmur?

<span class="section-blue">8.</span> Have you ever had a stroke, brain haemorrhage or brain injury, transient ischaemic attack(TIA), aneurysm, or any disease of the arteries or veins, including poor circulation in the legs?

<span class="section-blue">9.</span> Have you ever had treatment or advice for any form of cancer or malignant condition, leukaemia, Hodgkins disease, lymphoma, melanoma, or a benign brain or spinal tumour?

<span class="section-blue">10.</span> Have you ever had symptoms of or had treatment for epilepsy (including seizures, fits or blackouts), multiple sclerosis, optic neuritis, paralysis or any neurological condition?

<span class="section-blue">11.</span> Have you ever had symptoms of, treatment or investigations for trembling, numbness, loss of feeling or tingling in face, hands or feet or temporary loss of muscle power?

<span class="section-blue">12.</span> Have you ever had symptoms of or treatment for any disorder of the stomach, liver, pancreas or bowel (including Crohn’s disease, ulcerative colitis, polyps or ulcer)?

<span class="section-blue">13.</span> Have you ever had symptoms, treatment or advice for or been referred for any mental health problems including depression, self harm or psychiatric disorders including bipolar, mood or eating disorders?

<span class="section-blue">14.</span> Have you ever taken drugs for other than medicinal purposes, including the use of recreational drugs?

<span class="section-blue">15.</span> Have you ever tested positive for Hepatitis B or Hepatitis C, HIV or are you waiting for the results of such tests?

Medical and Other Information Continued.

<span class="section-blue">16.</span> Are you currently taking or have you been advised to take prescribed drugs, medicines or tablets, creams, inhalers, drops or sprays or have you taken such a course lasting more than two weeks within the past year?

<span class="section-blue">17.</span> Within the past five years have you been diagnosed with or had treatment for high blood pressure, high cholesterol, chest pains, an irregular heart beat or any blood disorder including haemochromatosis or anaemia?

<span class="section-blue">18.</span> Within the past five years have you had symptoms or had treatment for asthma, bronchitis, sarcoidosis, emphysema or any other disorder of the lungs or airways? First Life

<span class="section-blue">19.</span> Within the past five years have you noticed or had symptoms, treatment or advice for any cyst or lump including breast lump or cyst, an abnormal cervical smear, an abnormal mole or a growth whether seen by a doctor or not?

<span class="section-blue">20.</span> Within the past five years have you had symptoms of or treatment for any kidney, bladder, urinary disorder (including blood/protein in urine) or prostate disorder (including raised PSA level)?

<span class="section-blue">21.</span> Within the past five years have you had any symptoms of or treatment for any disorder of eyes (including any visual disturbance of the eyes, such as double vision or blurred vision) or the ears (including hearing impairment or loss of balance)?

<span class="section-blue">22.</span> Within the past five years have you had any symptoms of or treatment for any back or joint disorder (knees hips shoulders), arthritis, gout or any muscular disorder which required more than 10 consecutive days off work?

<span class="section-blue">23.</span> Within the past five years have you had any symptoms, treatment or advice for stress, anxiety, low mood, chronic fatigue or fibromyalgia?

<span class="section-blue">24.</span> Within the past five years, have you seen or been advised to see any specialist as an in-patient or out-patient at any hospital or clinic for any other illness or condition not already mentioned?

<span class="section-blue">25.</span> Within the past five years have you undergone or been advised to undergo any medical investigation including blood test, scan, imaging and x-ray or to have a surgical operation?

<span class="section-blue">26.</span> Within the past three years have you been unable to work for more than four consecutive weeks at a time?

<span class="section-blue">27.</span> Do you take part in or have any intention of taking part in any kind of hazardous leisure activity (including private flying, motor sports, mountaineering or scuba diving etc)?

<span class="section-blue">28.</span> Have you any intention of living or travelling outside of the EU, other than for holidays of less than 8 weeks duration, or have you resided out of the EU, North America, Australia or New Zealand for longer than one year in the last 10 years?

<span class="section-blue">29.</span> Have you ever been offered specical terms, postponed or declined for life cover, income protection or specified illness cover or have you made a claim for income protection or specified illness cover?

<span class="section-blue">30.</span> Have any of your parents, brothers or sisters ever had any of the following conditions before age 60?

Other questions for Income Insurance

<span class="section-blue">a.) </span> Do any of the following form an essential part of your work?

<span class="section-blue">b.) </span> What is the exact nature of the occupation from which you receive your earnings? Please provide full details of duties and the % of time spent at each duty

<span class="section-blue">c.) </span> Are you self employed?

<span class="section-blue">d.) </span> Have you ever received compensation or made an insurance claim for injury?

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