Income Protection Application Form

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

Personal Details
Title*
First Name*
Surname*
Correspondence Address*
Correspondence Address Eircode*
Date of Birth*
If your date of birth is incorrect any claim payment will be recalculated.
Marital Status*
Email Address*
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Phone Number*
Have you smoked or used any tobacco or nicotine replacement or e‑cigarettes in the last 12 months?
*
- Yes
- No

Save and Continue Later

You must answer these questions honestly and in full. If you give any incomplete or inaccurate answers this may result in the policy being cancelled from inception or any subsequent claim not being paid.
Lifestyle
If you have smoked or used any tobacco or nicotine replacement in the last 12 months, please advise amount per day.
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Height and Weight
Height*
Weight*
For height: eg 5'10 or 1.77m
For weight: eg 12st7 or 79kg
How many units of alcohol do you drink in a typical week?
How many units of alcohol do you drink in a typical 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
Have you ever been given medical advice to reduce your alcohol intake or had, or been advised to have, any form of treatment or counselling relating to your alcohol intake?
Have you ever been given medical advice to reduce your alcohol intake or had, or been advised to have, any form of treatment or counselling relating to your alcohol intake?*
- Yes
- No
If yes, please provide details*
Have you used illegal or recreational drugs during the last 10 years?
Have you used illegal or recreational drugs during the last 10 years?*
- Yes
- No
If yes, please provide details*
Have you lived, worked or travelled outside of the European Union, North America, Australia, New Zealand or Japan in the last 2 years or is it your intention to do so in the next 2 years. Ignore holidays of up to a month
Have you lived, worked or travelled outside of the European Union, North America, Australia, New Zealand or Japan in the last 2 years or is it your intention to do so in the next 2 years. Ignore holidays of up to a month*
- Yes
- No
If yes, please provide details*
Do you, or do you intend to, take part in hazardous sports or activities of any kind e.g. aviation (other than as a fare‑paying passenger), climbing, diving or motor sports? You do not need to disclose non‑hazardous team sports such as football, rugby or hurling
Do you, or do you intend to, take part in hazardous sports or activities of any kind e.g. aviation (other than as a fare‑paying passenger), climbing, diving or motor sports? You do not need to disclose non‑hazardous team sports such as football, rugby or hurling*
- Yes
- No
If yes, please provide details*

Save and Continue Later

Income Protection Application Form

Personal Details

Have you smoked or used any tobacco or nicotine replacement or e‑cigarettes in the last 12 months?

Cover Required

Form of cover

Annual amount of cover

Deferred period

At what age should cover end

Indexation

How do you wish to pay?

Is this to replace an existing Royal London or Caledonian Life Policy?

Doctor Details

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

Lifestyle

If you have smoked or used any tobacco or nicotine replacement in the last 12 months, please advise amount per day.

Height and Weight

How many units of alcohol do you drink in a typical week?

Have you ever been given medical advice to reduce your alcohol intake or had, or been advised to have, any form of treatment or counselling relating to your alcohol intake?

Have you used illegal or recreational drugs during the last 10 years?

Have you lived, worked or travelled outside of the European Union, North America, Australia, New Zealand or Japan in the last 2 years or is it your intention to do so in the next 2 years. Ignore holidays of up to a month

Do you, or do you intend to, take part in hazardous sports or activities of any kind e.g. aviation (other than as a fare‑paying passenger), climbing, diving or motor sports? You do not need to disclose non‑hazardous team sports such as football, rugby or hurling

Employment

Occupation

Are you involved in any of the following industries?

Are you

If you are Self‑Employed or a Shareholding Director, how many employees (including sub‑contractors) work for you?

How much did you earn (pre‑tax) over the last 12 months? Including overtime, commission and bonuses but not including investment income or income from other sources

Do you have another occupation in addition to the one stated above?

Does your job involve manual work, driving or working at heights?

Within the last 2 years have you had more than 10 consecutive days off work due to health issues or are you currently off work?

Health

Have you ever had any of the following:

<span class="section-blue">(a)</span> Any form of cancer, tumour, lymphoma, Hodgkin’s disease, leukaemia, melanoma or any brain or spinal growth or cyst?

<span class="section-blue">(b)</span> Disease or disorder of the heart (including valves) orcirculatory system, heart attack, angina, cardiomyopathy, disease of the arteries or peripheral vascular disease?

<span class="section-blue">(c)</span> A stroke, transient ischaemic attack (TIA/mini‑stroke), brain haemorrhage, aneurysm, brain injury or surgery to your blood vessels in the brain or neck?

<span class="section-blue">(d)</span> Multiple sclerosis, Parkinson’s disease, epilepsy, fit or seizure, Alzheimer’s disease, dementia, cerebral palsy, muscular dystrophy, motor neurone disease or had any other neurological disorder?

<span class="section-blue">(e)</span> Depression, anxiety, stress, insomnia, chronic fatigue syndrome, eating disorders or have you been referred to a psychiatrist or hospital clinic as a result of any mental illness?

<span class="section-blue">(f)</span> Diabetes, raised blood sugar or sugar in the urine, thyroid problems, goitre or glandular fever?

<span class="section-blue">(g)</span> A positive test for HIV/AIDS or Hepatitis B or C, or are you awaiting the results of such a test? If the result of a test you’re waiting on turns out to be negative, the fact you had a test won’t affect the terms we offer you

Apart from anything you have already told us about, <span class="section-grey"><u>during the last 5 years</u></span> have you had any of the following:

<span class="section-blue">(h)</span> Raised blood pressure, raised cholesterol, chest pain or irregular heart beat?

<span class="section-blue">(i)</span> Numbness, pins and needles, optic neuritis, double/blurred vision, tremor, tingling, muscle weakness, loss or reduced power in limbs, or persistent tiredness or fatigue? Please answer ‘yes’ whether seen by a doctor or not

<span class="section-blue">(j)</span> Any form of arthritis, gout, joint or ligament pain or neck, back, spine or muscle pain or stiffness?

<span class="section-blue">(k)</span> Any disorder affecting your ears or hearing, or your eyes or vision that is not wholly corrected by spectacles or lenses?

<span class="section-blue">(l)</span> A tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed in appearance or become painful? Please answer ‘yes’ whether seen by a doctor or not.

<span class="section-blue">(m)</span> Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your lungs or breathing?

<span class="section-blue">(n)</span> Any disorder of the digestive system, liver, stomach, pancreas or bowel (including any ulcer, hepatitis, colitis, Crohn’s disease or Barrett’s oesophagus)?

<span class="section-blue">(o)</span> Haemochromatosis , anaemia, vitamin b12 deficiency, clotting disorders or any other blood disorders?

<span class="section-blue">(p)</span> Any disorder of the kidney, bladder or prostate, including blood or protein in the urine or raised PSA (Prostate Specific Antigen)?

Apart from anything you have already told us about, <span class="section-grey"><u>during the last 3 years</u></span> have you:

Family medical history - have any of your natural parents or your brothers or sisters ever been diagnosed with or died from any of the following before age 60:

Have you ever had an application for Life, Specified Serious Illness or Income Protection cover declined, postponed or had special terms applied to it? If yes, please provide details of type and amount of cover, name of insurer and reason for the special terms.

Do you have any existing income protection cover in force or do you intend to take out any other income protection cover? If yes, please provide details of type and amount of cover and name of insurer.

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