Life Insurance Application Form

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

Please note carefully. The data entered on this form is a critical part of your application for Protection Cover. Your Financial Broker will keep the form and will enter the data into the Aviva on-line application data capture system. (See more details.)
We will send you a copy of the data entered by your Financial Broker on your behalf. It is your responsibility to ensure the data is correct; you should check it and if you do not agree with any of the data you should make the amendments, sign the document and immediately return it to us at our branch office, Aviva Life & Pensions Ireland, One Park Place, Hatch Street, Dublin 2. We will acknowledge receipt of any amendments within 10 days. If you do not receive this acknowledgement from us within 10 days, please contact us to ensure we have received your amendments.

This data, together with the Customer Application Booklet in Section B that you will sign, will be the basis of your application for Protection Cover.

Material facts are details that we need to know so we can assess applications for cover and claims for benefits. Material facts could include medical history, smoking history and details of occupation, travel and pastimes. If you do not tell us about material facts when you apply for your plan or at the claims stage, this might mean that your contract could be cancelled without premiums being returned, or, that we don’t pay a claim.

If you are in any doubt as to whether certain facts are material, you should tell us about them anyway. You must also tell us about any changes to the information you give us up until your policy starts.

In accordance with the Disability Act 2005, you should not tell us the results of any genetic tests which you have had.
Your life assured details
Title*
First Name*
Surname*
Address*
Date of Birth*
If your date of birth is incorrect any claim payment will be recalculated.
Day
Month
Year
Marital Status*
Occupation*
Email Address*
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Phone Number*
Is there a second applicant?*
- Yes
- No
Title*
First Name*
Surname*
Address*
Date of Birth*
If the second applicant's date of birth is incorrect any claim payment will be recalculated.
Day
Month
Year
Marital Status*
Occupation*
Email Address*
Opps! Something looks wrong with this email address.Looks great!
Phone Number*

Life Insurance Application Form

Please note carefully. The data entered on this form is a critical part of your application for Protection Cover. Your Financial Broker will keep the form and will enter the data into the Aviva on-line application data capture system. (See more details.)

Your life assured details

Insurance Required

Amount of Life Cover required

Doctor Details

First Life

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

First Life Previous Doctor Details

Second Life

If the second person has changed their doctor in the last year, please give the name and address of their previous doctor.

Second Life Previous Doctor Details

Part 1 Personal statements to be answered by the lives to be insured (Please answer carefully giving full details)

<span class="section-blue">1.1</span> Height and Weight

First Life

Second Life

<span class="section-blue">With regard to your use of cigarettes, cigars, pipe or other tobacco or nicotine replacement products (including E-cigarettes/vaping) - which of the following describes your smoking habits:

<span class="section-blue">1.3 (a)6. How many of the following alcoholic drinks do you have in a typical week?

<span class="section-blue">(b)</span> Have you ever been advised by a health care professional or doctor to stop, reduce or have a treatment for your alcohol use, or to see a Specialist or attend a support group because of your alcohol use?

<span class="section-blue">1.4</span> Have you had treatment for or used any recreational drugs in the last 10 years? Including: Cannabis, Cocaine, Ecstasy, Heroin, amphetamines, non-prescription sedatives, tranquilisers or anabolic steroids?

<span class="section-blue">1.5</span> Do you, or do you intend to, engage in hazardous pursuits?

<span class="section-blue">1.6</span> In the last 2 years, have you spent more than 90 days in total in Africa, the Caribbean or Thailand?

<span class="section-blue">1.7</span> In the next 2 years, apart from holidays amounting to less than 30 days in any year, do you intend to travel, live or work outside of Australia, Canada, the EU, New Zealand, Norway, Switzerland or the United States of America?

Your Occupation

<span class="section-blue">1.8</span> Do you work in any of the following industries?

Armed Forces, Aviation,Commercial Diving, Working at sea/fishing, Mining, Oil & Gas Exploration or Nuclear Energy, Quarrying / Tunnelling, With high voltage, explosives, hazardous materials or with furnaces

<span class="section-blue">1.9</span> Do you work at heights over 50ft (15m) for more than 10% of your time? If yes, what's the max height you work to?

Previous Applications

<span class="section-blue">1.10</span> Has any application been declined or postponed by Aviva or any other insurer or have you submitted a claim for Income Protection or Specified Illness cover?

Your family history

<span class="section-blue">1.11</span> Before the age of 60 have either of your natural parents or any brothers or sisters suffered or died from:

Part 2 - Personal Statements

Your health history

Do you currently have or have you ever had any of the following?

<span class="section-blue">2.1</span> Cancer (malignant tumour), leukaemia, Hodgkin’s disease or lymphoma?

<span class="section-blue">2.2</span> Heart attack or angina, heart abnormality or heart valve disease?

<span class="section-blue">2.3</span> Stroke, brain haemorrhage, transient ischaemic attack or permanent brain injury through accident?

<span class="section-blue">2.4</span> Any disease or disorder of the arteries (including disease in the legs or the aorta)?

<span class="section-blue">2.5</span> Multiple sclerosis, Parkinson’s disease, paralysis, epilepsy, Alzheimer’s disease or dementia?

<span class="section-blue">2.6</span> Any other disorder of the central nervous system (brain, spinal cord and nerves) not already mentioned?

<span class="section-blue">2.7</span> Diabetes or sugar in the urine?

<span class="section-blue">2.8</span> Mental illness that has required hospitalisation?

<span class="section-blue">2.9</span> Have you ever tested positive for HIV, Hepatitis B or C or are you awaiting the result of such a test?

Part 3 - Your health in the last 5 years

Apart from conditions already mentioned in Questions 2.1 – 2.9, in the last 5 years have you had any of the following:

<span class="section-blue">3.1</span> A lump or growth of any kind, or any mole or freckle that has bled, become painful, changed colour or increased in size?

<span class="section-blue">3.2</span> Chest pain, irregular heartbeat, raised blood pressure or raised cholesterol?

<span class="section-blue">3.3</span> Asthma, bronchitis or any other respiratory disorder?

<span class="section-blue">3.4</span> Numbness, loss of feeling or tingling of the limbs or face or temporary loss of muscle power?

<span class="section-blue">3.5</span> Seizure, fits, fainting, dizziness or blackouts?

<span class="section-blue">3.6</span> Disorder of the ears or eyes including optic neuritis and blurred or double vision (you can ignore sight problems corrected by glasses or contact lenses)?

<span class="section-blue">3.7</span> Arthritis, neck, spine or joint disorder (including slipped disc, sciatica, back, knee, shoulder pain or gout)?

<span class="section-blue">3.8</span> Any disorder of the digestive system, liver, stomach, pancreas or bowel (including any ulcer, hepatitis, colitis or Crohn’s disease)?

<span class="section-blue">3.9</span> Blood disorder or anaemia?

<span class="section-blue">3.10</span> Thyroid disorder?

<span class="section-blue">3.11</span> Kidney, bladder or any other disorder of the genito-urinary system (including blood or protein in the urine or urinary tract infection)?

<span class="section-blue">3.12</span> Any kind of depression, anxiety, stress, nervous breakdown, insomnia or fatigue?

Part 3 - Your health in the last 5 years continued

Apart from conditions already mentioned above:

<span class="section-blue">3.13</span> Have you had, or have you been advised to have any medical investigations, scans, tests, or treatment including mammograms, cervical smears, or PSA (you do not need to tell us about any routine pregnancy or infertility investigations, cold or flu).

<span class="section-blue">3.14</span> Are you awaiting the results of any tests/investigations or referral to any hospital, clinic or doctor?

<span class="section-blue">3.15</span> Do you have any medical condition, pain, discomfort or other symptoms for which you have not yet sought medical advice?

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