Mortgage Protection Application Form

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

First person to be covered
Title*
First Name*
Surname*
Date of Birth*
If your date of birth is incorrect any claim payment will be recalculated.
Sex*
Marital Status*
Employment Status*
Occupation*
Country of birth*
Country of birth
Country of citizenship*
Country of citizenship
Length of residency in Ireland*
If not resident, please state country of residence*
Annual Earned Income*
Address*
Email Address*
Opps! Something looks wrong with this email address.Looks great!
Phone*
Consent to seek information from other insurers:*
Information means medical and other relevant details given to an insurer by you or any doctor in connection with a life
insurance application on your life.
- Yes
- No
Is there a second applicant?*
- Yes
- No
Title*
First Name*
Surname*
Date of Birth*
If the second applicant's date of birth is incorrect any claim payment will be recalculated.
Sex*
Marital Status*
Employment Status*
Occupation*
Country of birth*
Country of birth
Country of citizenship*
Country of citizenship
Length of residency in Ireland*
If not resident, please state country of residence*
Annual Earned Income*
Consent to seek information from other insurers:*
- Yes
- No
Address*
Email Address*
Oops! Something looks wrong with this email address.Looks great!
Phone*
Replacement policy
Is this application to replace an existing New Ireland policy? If Yes, please provide policy number(s)
Is this application to replace an existing New Ireland policy? If Yes, please provide policy number(s)*
Note : It is not possible to cancel assigned policies without the prior written consent of the assignee (e.g bank/building society/credit union)
- Yes
- No
New Ireland Policy Number*

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Mortgage Protection Application Form

First person to be covered

Replacement policy

Is this application to replace an existing New Ireland policy? If Yes, please provide policy number(s)

Mortgage Protection Cover Details

Term of Cover (Between 2 and 40 years)

Amount of Cover

Doctor/Clinic 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

Occupation Details

What's your occupation?

First Life

Second Life

Risk Assessment

<span class="section-blue">1 a.</span> Have you smoked cigarettes, cigars, or pipe tobacco in the last 12 months?

<span class="section-blue">b.</span> If "Yes", how much do you smoke each day or if you have stopped smoking in the last 12 months how much did you smoke each day?

First Life:

Cigarettes - Amount per day

Cigars - Amount per week

Pipe Tobacco - Ounces per day

Second Life:

Cigarettes - Amount per day

Cigars - Amount per week

Pipe Tobacco - Ounces per day

<span class="section-blue">2.</span> How much alcohol do you drink each week?

First Life

Second Life

<span class="section-blue">3. a.</span> What is your height?

First Life

Second Life

<span class="section-blue">b.</span> What is your weight?

First Life

Second Life

Health

<span class="section-blue">1.</span> Do you currently have or have you ever had any of the following:

<span class="section-blue">a.</span> heart attack, angina, heart surgery, heart murmur, heart related chest pain or any other heart disease or disorder?

<span class="section-blue">b.</span> any form of cancer, malignant tumour, Hodgkin’s disease or lymphoma?

<span class="section-blue">c.</span> stroke, transient ischaemic attack (TIA or mini stroke), or brain haemorrhage?

<span class="section-blue">d.</span> multiple sclerosis, Parkinson’s disease, or any other brain or neurological disorder?

<span class="section-blue">e.</span> paralysis, numbness or tingling in the limbs or face, tremor, temporary loss of muscle power or lack of co-ordination, double / blurred vision or optic neuritis?

<span class="section-blue">f.</span> diabetes, thyroid problems, raised blood sugar, glucose intolerance or sugar in the urine?

<span class="section-blue">g.</span> hepatitis, other liver disorders, pancreatitis, ulcerative colitis or Crohn’s disease?

Risk Assessment Continued.

<span class="section-blue">2.</span> Have you ever had or been referred for treatment or counselling for alcohol excess or misuse, or have you ever been advised by a medical practitioner to cease or reduce your alcohol consumption?

<span class="section-blue">3.</span> Have you ever used any recreational drugs such as cannabis, cocaine, heroin, ecstasy, amphetamines, anabolic steroids or non-prescription sedatives?

<span class="section-blue">4.</span> Have you ever tested positive for HIV or are you awaiting the result of a HIV test?

<span class="section-blue">5.</span> <span class="section-grey"><u>In the last 5 years</u></span> have you had, or do you currently have any of the following:

<span class="section-blue">a.</span> Asthma, bronchitis, emphysema or any other lung or breathing disorder?

<span class="section-blue">b.</span> High blood pressure or raised cholesterol?

<span class="section-blue">c.</span> Depression, stress, anxiety, eating disorders, chronic fatigue syndrome or other nervous or mental disorder?

<span class="section-blue">d.</span> Cyst, lump, polyp, growth of any kind, or any mole that has: bled, become painful, changed colour or increased in size?

<span class="section-blue">e.</span> Epilepsy, seizure, fit, fainting, dizziness, blackouts, severe headaches or migraines?

<span class="section-blue">f.</span> Back and / or neck disorders including disc problems, sciatica, whiplash, back and / or neck pain or trapped nerves?

<span class="section-blue">g.</span> Arthritis, rheumatoid / psoriatic arthritis or any other joint problems?

<span class="section-blue">h.</span> Disorder of the digestive system or stomach, including reflux, ulcers, hernia or Coeliac disease?

<span class="section-blue">i.</span> Disorder of the eyes that is not corrected by spectacles or contact lenses including: impaired vision or blindness?

<span class="section-blue">j.</span> Disorder of the ears, nose or throat including: hearing impairment / deafness, tinnitus or vertigo?

<span class="section-blue">k.</span> Anaemia, deep vein thrombosis (DVT), haemochromatosis or other blood disorders?

<span class="section-blue">l.</span> Kidney disorder, disease or surgery, or prostate problems? (males only) || Kidney disorder, disease or surgery? (females only)

<span class="section-blue">m.</span> Abnormal smear test results, hysterectomy, endometriosis, fibroids, ovarian cysts or mammogram which required further investigation? (females only)

Risk Assessment Continued.

<span class="section-blue">6.</span> Have you had any medical investigations, scans or tests within the last 5 years?

<span class="section-blue">7.</span> Are you taking, or have you been advised to take, any prescribed drug(s), medicine(s), tablet(s) or any other treatment(s)?

<span class="section-blue">8.</span> Are you awaiting any medical referral, medical investigation(s), medical test result(s), surgical procedure or intending to seek medical advice or treatment for any reason (e.g. unexpected weight loss, change in bowel habit, a growth, cyst or lump)?

Concerning your family:

<span class="section-blue">9.</span> Have any of your biological parents, brothers or sisters had any of the following medical conditions before age 60:

<span class="section-blue">(i)</span> cancer of the breast, ovaries, colon, bowel, rectum, polyposis of the colon or any other form of cancer?

<span class="section-blue">(ii)</span> heart attack, angina, heart by-pass, angioplasty, heart failure, cardiomyopathy, stroke, diabetes, haemochromatosis, high blood pressure or raised cholesterol?

<span class="section-blue">(iii)</span> multiple sclerosis, Huntington’s disease, polycystic kidney disease, motor neurone disease, muscular dystrophy, Parkinson’s disease or Alzheimer’s disease?

<span class="section-blue">10.</span> Apart from the conditions listed above, have 2 or more of any of your biological parents, brothers or sisters had the same condition before age 60?

About your travel and interests:

<span class="section-blue">11.</span> In the last 10 years, have you spent more than 6 months in total travelling or residing in a country, continent or area other than the European Union (EU), United States of America (USA), Canada, Japan, Singapore, Hong Kong, New Zealand or Australia?

<span class="section-blue">12.</span> In the next 12 months, do you intend to travel or reside for more than 30 days in total in a country, continent or area other than the European Union (EU), United States of America (USA), Canada, Japan, Singapore, Hong Kong, New Zealand or Australia?

<span class="section-blue">14.</span> Will your total cover with us or any other insurer (including existing cover, this application and any other application for cover, excluding group risk cover)

<span class="section-blue">a.</span> exceed the sum of €1,250,000 for life cover?