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.
However, it is important that you are aware that in accordance with the provisions of Part 4 of the Disability Act 2005 you should NOT disclose the result of any Genetic (DNA or RNA) test. Some medical conditions are genetic and can be passed from generation to generation. Advances in medical science have made it possible in certain circumstances to take a genetic test and to ascertain if a specific condition has been passed on. If you have had such a genetic test then you should not disclose it.
You must disclose if you are having treatment for, experiencing symptoms of, or having investigations (other than a genetic test) for a genetic condition as well as disclosing all other conditions. You must also give us full information about your family history (without disclosing the name of any relatives), including all genetic conditions as requested in Question 14 below.
Section 41 of the Disability Act defines 'genetic testing' as the examination of samples taken from a living person for the purpose of analysing the person’s deoxyribonucleic (DNA) or ribonucleic acid (RNA) by means of chromosomal analysis or by any other means for the purpose of:
(a) confirming the identity or nature of an existing symptomatic disease;
(b) ascertaining whether the person has a genetic predisposition or susceptibility to a disease; or
(c) identifying the carrier of a disease.
Send Form To