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Inflammatory Bowel Disease
Diabetes
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9:30 - 5:30 MON - FRI
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Life Insurance 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.
Your life assured details
Title
*
Title
Mr
Mrs
Ms
First Name
*
Surname
*
Correspondence Address
*
Correspondence Address Eircode
*
Date of Birth
*
If your date of birth is incorrect any claim payment will be recalculated.
Day
1
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31
Month
1
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Year
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1994
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1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
Marital Status
*
Marital Status
Married
Single
Separated
Divorced
Widowed
Email Address
*
Opps! Something looks wrong with this email address.
Looks great!
Phone Number
*
Have you smoked or used any tobacco or nicotine replacement or e‑cigarettes in the last 12 months? We may require you to perform a simple test to confirm this.
Have you smoked or used any tobacco or nicotine replacement or e‑cigarettes in the last 12 months? We may require you to perform a simple test to confirm this.
*
Yes
No
Is there a second applicant?
*
Yes
No
Title
*
Title
Mr
Mrs
Ms
First Name
*
Surname
*
Address Line 1
*
Address Line 2
*
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
Marital Status
*
Marital Status
Married
Single
Separated
Divorced
Widowed
Email Address
*
Opps! Something looks wrong with this email address.
Looks great!
Phone Number
*
Have you smoked or used any tobacco or nicotine replacement or e‑cigarettes in the last 12 months? We may require you to perform a simple test to confirm this.
Have you smoked or used any tobacco or nicotine replacement or e‑cigarettes in the last 12 months? We may require you to perform a simple test to confirm this.
*
Yes
No
Insurance Required
Term of Cover
Term of Cover
*
Basis of Cover:
*
Joint
Dual
Additional benefits:
Add Indexation
Add Guaranteed Cover option
Indexation option explained
|
Guaranteed cover explained
Amount of Life Cover required
First Life (for Single or Joint Life applications)
*
For how much do you wish to insure yourself?
Second Life (for Joint Life applications)
*
Add Accelerated Serious Illness Cover required
*
No
Yes
First Life Serious Illness Sum Insured (both lives if Joint Life policy)
*
Second Life Serious Illness Sum Insured (both lives if joint life policy)
*
Bank Drafts and Cheques should be made payable to Zurich Life.
Premium frequency:
*
Monthly direct debit
Annually
Doctor Details
First Life
Doctor's name
*
Years with doctor
*
Less than 1
Over 1
Address
*
Previous Doctor's name and address
*
Second Life
Doctor's name
*
Years with doctor
*
Less than 1
More than 1
Address Line 1
*
Previous Doctor's name and address
*
Health Details
First Life
Height
*
Weight
*
Second Life
Height
*
Weight
*
If you have smoked or used any tobacco or nicotine replacement in the last 12 months, please advise amount per day <span class="section-grey">(including electronic cigarettes)</span>
First Life:
*
Yes
No
If YES, please advise the amount smoked per day
*
Second Life:
*
Yes
No
If YES, please advise the amount smoked per day
*
How many units of alcohol do you drink in a typical week? <span class="section-grey">one pint of beer or 175ml glass of wine = 2 units, one 25ml measure of spirits = 1 unit</span>
First Life:
*
Second Life:
*
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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
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. <span class="section-grey">Ignore holidays of up to a month</span>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
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? <span class="section-grey">You do not need to disclose non‑hazardous team sports such as football, rugby or hurling</span>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
Employment
First Life Occupation
*
Second Life Occupation
*
Health
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.
Have you ever had any of the following:
<span class="section-blue">(Q1)</span> Any form of cancer, tumour, lymphoma, Hodgkin’s disease, leukaemia, melanoma or any brain or spinal growth or cyst?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q2)</span> Disease or disorder of the heart (including valves) or circulatory system, heart attack, angina cardiomyopathy, disease of the arteries or peripheral vascular disease?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q3)</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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q4)</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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q5)</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?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q6)</span> Diabetes, raised blood sugar or sugar in the urine, thyroid problems, goitre orglandular fever?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q7)</span> A positive test for HIV/AIDS or Hepatitis B or C, or are you awaiting the results of such a test? <i class="section-grey">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.</i>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">Apart from anything you have already told us about, <u>during the last 5 years</u> have you had any of the following:</span>
<span class="section-blue">(Q8)</span> Raised blood pressure, raised cholesterol, chest pain or irregular heart beat?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q9)</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? <i class="section-grey">Please answer ‘yes’ whether seen by a doctor or not.</i>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
Health contd.
<span class="section-blue">(Q10)</span> Any form of arthritis, gout, joint or ligament pain or neck, back, spine/muscle pain?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q11)</span> Any disorder affecting your ears or hearing, or your eyes or vision that is not whollyu0003 corrected by spectacles or lenses?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q12)</span> A tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed inu0003 appearance or become painful? <i class="section-grey">Please answer ‘yes’ whether seen by a doctor or not.</i>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q13)</span> Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your u0003lungs or breathing?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q14)</span> Any disorder of the digestive system, liver, stomach, pancreas or bowel (including u0003any ulcer, hepatitis, colitis, Crohn’s disease or Barrett’s oesophagus)?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q15)</span> Haemochromatosis , anaemia, vitamin b12 deficiency, clotting disorders or any otheru0003 blood disorders?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q16)</span> Any disorder of the kidney, bladder or prostate, including blood or protein in the u0003urine or raised PSA (Prostate Specific Antigen)?
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">Apart from anything you have already told us about, <u>during the last 3 years</u> have you:</span>
<span class="section-blue">(Q17)</span> Regularly been prescribed medication or treatment lasting for a period of 4 weeks u0003or more, or have you been under review from your doctor or a medical professional?u0003 <i class="section-grey">You don’t need to tell us about contraception, fertility or reviews purely in relation to pregnancy.</i>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q18)</span> Been referred to a specialist, undergone or been advised to have any tests oru0003 investigations? <i class="section-grey">For example: Abnormal smear or mammogram, biopsy, colonoscopy, scans or u0003blood tests. You do not need to tell us about investigations which were purely for pregnancy,u0003infertility or simple fractures.</i>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
<span class="section-blue">(Q19)</span> Apart from anything you have already told us about, are you awaiting referral,u0003results or treatment for anything else or do you have any other symptoms for which you u0003have not yet sought medical advice? <i class="section-grey">For example: Bleeding from the bowels or change in bowel u0003habit, persistent cough, weight loss, onset of fits or seizures, dizziness, blackouts or fainting.</i>
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
Health contd.
Family medical history - have any of your natural parents, brothers or sisters ever been u0003diagnosed with or died from any of the following before age 60?
Heart Attack or Angina, Cancer (including Leukaemia or Lymphoma), Multiple Sclerosis,u0003Muscular Dystrophy, Motor Neurone Disease, Cardiomyopathy, Polycystic Kidney Disease,u0003Familial Colon Polyps, Stroke, Diabetes, Huntington’s Disease, Alzheimer’s Disease,u0003Parkinson’s Disease, Haemochromatosis.
If yes then please provide details. If the condition is cancer, please be specific as to theu0003 type of cancer.
First Life:
*
Yes
No
If YES, add details here
*
Second Life:
*
Yes
No
If YES, add details here
*
If YES and you have had any tests or check‑ups as a result of relative’s medical condition, u0003please capture details here. In line with the Disability Act 2005, the results of any geneticu0003 tests should not be disclosed.
Add details here
*
Have you ever had an application for Life, Specified Serious Illness or Income Protection cover declined, postponed or had special terms applied to it?
First Life:
*
Yes
No
Add details here
*
Second Life:
*
Yes
No
Add details here
*
If you are currently applying for Specified Serious Illness cover do you intend taking out cover (incl. this application) in excess of €500,000 Specified Serious Illness cover?
First Life:
*
Yes
No
Second Life:
*
Yes
No
Do you intend taking out total cover (including this application and any existing cover in force with this or any other company) in excess of €5,000,000 Life cover?
First Life:
*
Yes
No
Second Life:
*
Yes
No
Would You Like 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.
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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