Royal London Life Insurance Application Form

Your life assured 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? 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*
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.
Marital Status*
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

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Life Insurance Application Form

Your life assured details

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.

Insurance Required

Term of Cover

Amount of Life Cover required

Doctor Details

First Life

Second Life

Health Details

First Life

Second Life

If you have smoked or used any tobacco or nicotine replacement in the last 12 months, please advise amount per day (including electronic cigarettes)

How many units of alcohol do you drink in a typical week? one pint of beer or 175ml glass of wine = 2 units, one 25ml measure of spirits = 1 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 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

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:

(Q1) Any form of cancer, tumour, lymphoma, Hodgkin’s disease, leukaemia, melanoma or any brain or spinal growth or cyst?

(Q2) Disease or disorder of the heart (including valves) or circulatory system, heart attack, angina cardiomyopathy, disease of the arteries or peripheral vascular disease?

(Q3) A stroke, transient ischaemic attack (TIA/mini-stroke), brain haemorrhage,aneurysm, brain injury or surgery to your blood vessels in the brain or neck?

(Q4) 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?

(Q5) 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?

(Q6) Diabetes, raised blood sugar or sugar in the urine, thyroid problems, goitre orglandular fever?

(Q7) 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, during the last 5 years have you had any of the following:

(Q8) Raised blood pressure, raised cholesterol, chest pain or irregular heart beat?

(Q9) 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.

Health contd.

(Q10) Any form of arthritis, gout, joint or ligament pain or neck, back, spine/muscle pain?

(Q11) Any disorder affecting your ears or hearing, or your eyes or vision that is not whollyu0003 corrected by spectacles or lenses?

(Q12) A tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed inu0003 appearance or become painful? Please answer ‘yes’ whether seen by a doctor or not.

(Q13) Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your u0003lungs or breathing?

(Q14) Any disorder of the digestive system, liver, stomach, pancreas or bowel (including u0003any ulcer, hepatitis, colitis, Crohn’s disease or Barrett’s oesophagus)?

(Q15) Haemochromatosis , anaemia, vitamin b12 deficiency, clotting disorders or any otheru0003 blood disorders?

(Q16) Any disorder of the kidney, bladder or prostate, including blood or protein in the u0003urine or raised PSA (Prostate Specific Antigen)?

Apart from anything you have already told us about, during the last 3 years have you:

(Q17) 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 You don’t need to tell us about contraception, fertility or reviews purely in relation to pregnancy.

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?

If yes then please provide details. If the condition is cancer, please be specific as to theu0003 type of cancer.

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.

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 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?

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?

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