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Cover Types
Life Insurance
Mortgage Protection
Income Protection Insurance
Serious Illness Cover
Illness Advice
Life Cover with a Health Issue
Cancer
Mental Health
Weight Issues
Inflammatory Bowel Disease
Diabetes
Multiple Sclerosis
Insurers
Aviva
Irish Life
New Ireland
Royal London
Zurich Life
Learning Hub 🎓
Insurance Academy
Downloadable Guides & Courses
Life Insurance FAQs
Blog
About
Contact
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057 93 20836
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9:30 - 5:30 MON - FRI
Search for:
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
*
Title
Mr
Mrs
Ms
First Name
*
Surname
*
Date of Birth
*
If your date of birth is incorrect any claim payment will be recalculated.
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
Sex
*
Sex
Male
Female
Marital Status
*
Marital Status
Single
Married
Separated
Divorced
Civil Partner
Partner
Co Habitee
Employment Status
*
Employment Status
Employee
Self-employed
Homemaker
Student
Retired
Unemployed
Occupation
*
Country of birth
*
Country of birth
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
CĂ´te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
RĂ©union
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
TĂĽrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ă…land Islands
Country of birth
Country of citizenship
*
Country of citizenship
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
CĂ´te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
RĂ©union
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
TĂĽrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ă…land Islands
Country of citizenship
Length of residency in Ireland
*
Length of residency in Ireland
More than 5 years
2-5 years
1-2 years
Less than 1 year
Not resident
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
*
Title
Mr
Mrs
Ms
First Name
*
Surname
*
Date of Birth
*
If the second applicant's date of birth is incorrect any claim payment will be recalculated.
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
Sex
*
Sex
Mr
Mrs
Ms
Marital Status
*
Marital Status
Single
Married
Separated
Divorced
Civil Partner
Partner
Co Habitee
Employment Status
*
Employment Status
Employee
Self-employed
Homemaker
Student
Retired
Unemployed
Occupation
*
Country of birth
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
CĂ´te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
RĂ©union
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
TĂĽrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ă…land Islands
Country of birth
Country of citizenship
*
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
CĂ´te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
RĂ©union
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
TĂĽrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ă…land Islands
Country of citizenship
Length of residency in Ireland
*
Length of residency in Ireland
More than 5 years
2-5 years
1-2 years
Less than 1 year
Not resident
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
*
Mortgage Protection Cover Details
Term of Cover (Between 2 and 40 years)
Years of Cover
*
For how long do you wish to insure yourself? Minimum 2 , maximum 40 years
Please enter a number from
2
to
40
.
Amount of Cover
Amount of cover
*
For what amount do you wish to insure yourself
Add Specified Illness Cover?
*
Yes
No
Amount of specified illness cover
*
Only illnesses specified in your policy document are covered under Serious Illness benefit. Claims for
any other serious or minor illnesses are not covered.
Medical Free Conversion
*
This allows you to convert your remaining mortgage protection into a life insurance policy in the future without answering medical questions.
Yes
No
Doctor/Clinic Details
First Life
Doctor's name
*
Years with doctor
*
1
2
3
4
5
6
7
8
9
10+
Address Line 1
*
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
Previous Doctor's name
*
Previous Doctor's Address
*
Second Life
Doctor's name (Second Person)
*
Years with doctor
*
1
2
3
4
5
6
7
8
9
10
Address Line 1
*
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
Previous Doctor's name
*
Address Line 1
*
Occupation Details
What's your occupation?
First Life
First Life Occupation
*
Second Life
Second Life Occupation
*
Risk Assessment
<span class="section-blue">1 a.</span> Have you smoked cigarettes, cigars, or pipe tobacco in the last 12 months?
First Life
*
Yes
No
Second Life
*
Yes
No
<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
First Life Cigarettes
*
Amount per day. Enter 0 if you don't smoke cigarettes
Cigars - Amount per week
First Life Cigars
*
Amount per day. Enter 0 if you don't smoke cigars
Pipe Tobacco - Ounces per day
First Life Pipe tobacco
*
Ounces per day. Enter 0 if you don't smoke Pipe tobacco
Second Life:
Cigarettes - Amount per day
Second Life Cigarettes
*
Amount per day. Enter 0 if you don't smoke cigarettes
Cigars - Amount per week
Second Life Cigars
*
Amount per day. Enter 0 if you don't smoke cigars
Pipe Tobacco - Ounces per day
Second Life Pipe tobacco
*
Ounces per day. Enter 0 if you don't smoke Pipe tobacco
<span class="section-blue">2.</span> How much alcohol do you drink each week?
First Life
First Life
*
Pint beer = 2 units, Bottle beer = 1.5 units, Measure spirits = 1 unit, Bottle wine = 7 units, Glass wine = 1 unit. Enter 0 if you do not drink alcohol. Second Life
Second Life
Second Life
*
Pint beer = 2 units, Bottle beer = 1.5 units, Measure spirits = 1 unit, Bottle wine = 7 units, Glass wine = 1 unit. Enter 0 if you do not drink alcohol.
<span class="section-blue">3. a.</span> What is your height?
First Life
Height
*
Second Life
Height
*
<span class="section-blue">b.</span> What is your weight?
First Life
Weight
*
Second Life
Weight
*
Health
Please provide details about any disclosure(s) below such as:
- exact condition
- when diagnosed
- tests / investigations results
- treatment
- any current medication
- date of last review with your GP / specialist.
If you give a lot of information upfront, the insurer may not ask for anything further. This will speed up your application.
<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?
First Life:
*
Yes
No
If YES, please specify
*
Second Life:
*
Yes
No
If YES, please specify
*
<span class="section-blue">b.</span> any form of cancer, malignant tumour, Hodgkin’s disease or lymphoma?
First Life:
*
Yes
No
If YES, add details here
*
If you have already given us the Histology of the tumour, please type "already discussed" in this section.
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">c.</span> stroke, transient ischaemic attack (TIA or mini stroke), or brain haemorrhage?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">d.</span> multiple sclerosis, Parkinson’s disease, or any other brain or neurological disorder?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">f.</span> diabetes, thyroid problems, raised blood sugar, glucose intolerance or sugar in the urine?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">g.</span> hepatitis, other liver disorders, pancreatitis, ulcerative colitis or Crohn’s disease?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">4.</span> Have you ever tested positive for HIV or are you awaiting the result of a HIV test?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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:
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">a.</span> Asthma, bronchitis, emphysema or any other lung or breathing disorder?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">b.</span> High blood pressure or raised cholesterol?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">c.</span> Depression, stress, anxiety, eating disorders, chronic fatigue syndrome or other nervous or mental disorder?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">e.</span> Epilepsy, seizure, fit, fainting, dizziness, blackouts, severe headaches or migraines?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">f.</span> Back and / or neck disorders including disc problems, sciatica, whiplash, back and / or neck pain or trapped nerves?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">g.</span> Arthritis, rheumatoid / psoriatic arthritis or any other joint problems?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">h.</span> Disorder of the digestive system or stomach, including reflux, ulcers, hernia or Coeliac disease?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">i.</span> Disorder of the eyes that is not corrected by spectacles or contact lenses including: impaired vision or blindness?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">j.</span> Disorder of the ears, nose or throat including: hearing impairment / deafness, tinnitus or vertigo?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">k.</span> Anaemia, deep vein thrombosis (DVT), haemochromatosis or other blood disorders?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">l.</span> Kidney disorder, disease or surgery, or prostate problems? (males only) || Kidney disorder, disease or surgery? (females only)
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">m.</span> Abnormal smear test results, hysterectomy, endometriosis, fibroids, ovarian cysts or mammogram which required further investigation? (females only)
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
Risk Assessment Continued.
<span class="section-blue">6.</span> Have you had any medical investigations, scans or tests within the last 5 years?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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)?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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)?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
Concerning your family:
If you answer yes to 9 (i), (ii) or (iii), then please give the following in the details box: Relative (parent, brother, sister), Age at Diagnosis, Details of any check-up/screening you have undergone. (If cancer, specify the part of the body affected first, eg. bowel) (If heart disease, specify exact nature of heart disease)
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">13.</span> Do you take part in or intend to take part in any hazardous leisure activities or sports such as scuba diving, motor sports, aviation, water sports, horse riding, martial arts, mountaineering, caving or winter / ice sports? If yes, please complete the appropriate questionaire.
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">b.</span> exceed the sum of €500,000 for specified illness cover?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
Bank Details
New Ireland requires your bank details in advance. If you prefer to give them to us over the phone, that's ok with us, please call us on (01) 693 3382
IBAN
*
Do you need advice?
Would you like advice, or are you happy to proceed on an execution-only basis?
*
Execution-only basis means you are proceeding without receiving advice or recommendations about which product is most suitable for you.
I would like advice
I am happy to proceed on an execution-only basis.
Terms of Business
Term of Business
*
Lion.ie is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. There is an one click unsubscribe button on every email we send.
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