Life Insurance Application Form

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

Life Insurance Application Form
Important note for customers: All of the information you provide in the Personal Information Form must be true and complete otherwise payment of any future benefits may be affected (See more details.)
WARNING: When completing this application form you must disclose all Material Facts. A Material Fact is any fact about your health, family history, smoking or drinking habits, occupation, pastimes, policies with other insurance companies or any other fact that may increase the risk of you making a claim or influence the assessment and acceptance of your application by Zurich Life Assurance plc ('Zurich Life'). You must also advise Zurich Life immediately of any Material Facts or change in Material Facts that come to light between the date you sign the application form and the date the policy is issued. If you fail to disclose all Material Facts or provide Zurich Life with full and accurate information any subsequent claim may be rejected and your policy cancelled from the inception date. If you are in any doubt about whether a fact is material you should disclose full details.

Your commitment to provide honest and complete information to us:
- I am aware that if I do not answer all questions honestly and completely, then Zurich Life may not pay out if I need to make a claim in the future.
- I understand that Zurich Life will not necessarily obtain a report from my doctor, so it is vital that I fully disclose all Material Facts (see overleaf).
- I understand that Zurich Life will assess my application based on the information in this form.
- I understand that it is my responsibility to check that my completed application is honest and complete before submitting it to Zurich Life.
Life/Lives Insured Details
Title*
First Name*
Surname*
Correspondence Address*
Correspondence Address
Date of Birth*
If your date of birth is incorrect any claim payment will be recalculated.
Day
Month
Year
Civil Status*
Nationality*
Nationality
Country of Residence*
Country of Residence
Email Address*
Opps! Something looks wrong with this email address.Looks great!
Phone*
Are you a Politically Exposed Person (PEP)?
A politically exposed person (PEP) is a person that is, or has at any time in the past 12 months been, entrusted with a prominent public function, including any of the following individuals (but not including any middle ranking or more junior official): a head of state, head of government, government minister, or deputy or assistant government minister; a member of a parliament; a member of a supreme court, constitutional court, or other high-level judicial body whose decisions, other than in exceptional circumstances, are not subject to further appeal; a member of a court of auditors or of the board of a central bank; an ambassador, chargé d'affairs, or high-ranking officer in the armed forces; or a member of the administrative management, or supervisory body of a state-owned enterprise. This is not an exhaustive list. A spouse (or equivalent under the law of where the PEP lives), child, spouse of a child, or parent of a PEP is also a PEP.
- No
- Yes
Is there a second person to be insured?*
- Yes
- No
Title*
First Name*
Surname*
Correspondence Address*
Date of Birth*
If the second applicant's date of birth is incorrect any claim payment will be recalculated.
Day
Month
Year
Civil Status*
Nationality*
Nationality
Country of Residence*
Country of Residence
Email Address*
Oops! Something looks wrong with this email address.Looks great!
Phone*
Are you a Politically Exposed Person (PEP)?
A politically exposed person (PEP) is a person that is, or has at any time in the past 12 months been, entrusted with a prominent public function, including any of the following individuals (but not including any middle ranking or more junior official): a head of state, head of government, government minister, or deputy or assistant government minister; a member of a parliament; a member of a supreme court, constitutional court, or other high-level judicial body whose decisions, other than in exceptional circumstances, are not subject to further appeal; a member of a court of auditors or of the board of a central bank; an ambassador, chargé d'affairs, or high-ranking officer in the armed forces; or a member of the administrative management, or supervisory body of a state-owned enterprise. This is not an exhaustive list. A spouse (or equivalent under the law of where the PEP lives), child, spouse of a child, or parent of a PEP is also a PEP.
- No
- Yes

Life Insurance Application Form

Life Insurance Application Form

Important note for customers: All of the information you provide in the Personal Information Form must be true and complete otherwise payment of any future benefits may be affected (See more details.)

Life/Lives Insured Details

Life Insurance

Term of Cover / Years

Main Benefits

Payment Details

Non-smoker Declaration

In the last 12 months, which of the following best describes your smoking habits:

Health Statement and Other Information

Important note. When answering the questions in this section you must give full and accurate information in relation to all Material Facts. (See more details.)

In relation to the COVID-19 virus please confirm:

First Life

Second Life

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

Personal Details

<span class="section-blue">1.</span> Height & Weight

<span class="section-blue">(i)</span> Height

First Life

Second Life

<span class="section-blue">(ii)</span> Weight

First Life

Second Life

<span class="section-blue">2.</span> Do you smoke tobacco?

If NO, to apply for non-smoker rates you must have completed the Non-smoker Declaration of this application form (above). If YES, please enter the amount of all tobacco products below:

First Life

Cigarettes - Amount per day

Cigars - Amount per day

Pipe Tobacco - Grams per day

Second Life

Cigarettes - Amount per day

Cigars - Amount per day

Pipe Tobacco - Grams per day

<span class="section-blue">3. </span>Do you drink alcohol?

What is your average weekly consumption in units?

First Life

Second Life

Occupation/Activities/Travel

<span class="section-blue">4.</span> Please state your occupation

First Life

Second Life

<span class="section-blue">5.</span> As part of your occupation, do you work at heights greater than 40 feet / 12 metres or underground or carry out any other potentially hazardous activity?

<span class="section-blue">6.</span> Do you have any intention of flying other than as a passenger on a public airline?

<span class="section-blue">7.</span> Have you travelled or resided outside the EU for more than 3 months in the last 5 years? (Travel to USA, Canada, Australia or New Zealand need not be disclosed.)

<span class="section-blue">8.</span> Do you have any intention or prospect of travelling or residing outside the EU other than on a holiday of less than 3 months duration? (Travel to USA, Canada, Australia or New Zealand need not be disclosed.)

<span class="section-blue">9 a.</span> Do you take part or intend to take part in any hazardous pastime such as motor racing, diving, aviation or mountaineering?

<span class="section-blue">9 b. </span> Have you received a conviction for drink driving or driving under the influence of a controlled substance in the past 5 years?

Health

<span class="section-blue">10.</span> Have you ever suffered from or received treatment, advice or had investigations for any of the following:

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

<span class="section-blue">(ii)</span> Heart attack, angina, cardiac failure, cardiomyopathy, heart valve or structural disorders or other heart disease?

<span class="section-blue">(iii)</span> Stroke, brain haemorrhage or brain injury through any cause?

<span class="section-blue">(iv)</span> Disease of the arteries or veins, aortic aneurysms, or poor circulation in the legs?

<span class="section-blue">(v)</span> Disease or disorder of the blood, including anaemia?

<span class="section-blue">(vi)</span> Multiple sclerosis, optic neuritis, Parkinson’s disease, Alzheimer’s disease, dementia or paralysis from any cause?

<span class="section-blue">(vii)</span> Epilepsy or any other disease of the nervous system (brain, spinal cord or nerves)?

<span class="section-blue">(viii)</span> Cirrhosis or any other illness affecting the liver.

<span class="section-blue">(ix)</span> Kidney failure or kidney disease including cystic kidney disease?

<span class="section-blue">(ix)</span> Diabetes, thyroid disorders or any hormone abnormalities?

Health Continued

<span class="section-blue">11.</span> <span class="section-grey"><u>In the last 5 years</u></span> have you suffered from or received treatment, advice or had investigations for any of the following:

<span class="section-blue">(i)</span> Lump, growth, cyst, mole or freckle that has bled, changed shape, colour or size or become painful?

<span class="section-blue">(ii)</span> High blood pressure, raised cholesterol, chest pain or irregular heart beat?

<span class="section-blue">(iii)</span> Any form of numbness or tingling, temporary loss of muscle power or tremor, severe headaches, dizziness, seizure, fit, fainting or blackout or any other symptom that may be due to a nervous system disorder?

<span class="section-blue">(iv)</span> Ulcers or any disorder of the oesophagus, intestine, pancreas, bowel or urinary system?

<span class="section-blue">(v)</span> Asthma, bronchitis, emphysema, shortness of breath or any other respiratory disorder? (Colds, influenza, hay fever and simple respiratory tract infections can be omitted.)

<span class="section-blue">(vi)</span> Disorders affecting the eye (and not wholly corrected by spectacles or contact lenses), ear, nose or throat

<span class="section-blue">(vii)</span> Arthritis or joint disorders, back, neck or muscular disorder or chronic fatigue syndrome?

<span class="section-blue">(viii)</span> Male Lives - Prostate or any other urinary disorders. Female Lives - Abnormal cervical smear or any other gynaecological or urinary disorder.

<span class="section-blue">(ix)</span> Other than for the conditions you have already disclosed, are you taking any prescribed drugs, medicines, tablets or any other treatment at present? (Please give the name of the condition for which you are taking this treatment and not the medication itself.)

<span class="section-blue">(x)</span> Other than the conditions disclosed above have you sought medical advice, treatment or had investigations for any other condition in the past 5 years? (Colds, influenza and hay fever can be omitted.)

<span class="section-blue">(xi)</span> Are you awaiting the results of any tests / investigations or referral to any hospital, clinic or doctor or do you have any medical condition, pain, discomfort or other symptoms for which you have not yet sought medical advice?

Health Continued

<span class="section-blue">12 (i)</span> Have you used any nicotine replacement products in the past 12 months? This may include electronic cigarettes, nicotine patches or gum. (Please confirm type of product used)