MP | Zurich Life | 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.

Mortgage Protection Application Form

Title*

First Name*

Surname*

Correspondence Address*

Date of Birth*

If your date of birth is incorrect any claim payment will be recalculated.

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.

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

Mortgage Protection 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.

Mortgage Protection Application Form

Mortgage Protection

Term of Cover

Mortgage Amount

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

DOCTOR DETAILS

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 drink alcohol?

What is your average weekly consumption in units?

First Life

Second Life

Occupation/Activities/Travel

<span class="section-blue">3.</span> Please state your occupation

First Life

Second Life

<span class="section-blue">4.</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">5.</span> Do you have any intention of flying other than as a passenger on a public airline?

<span class="section-blue">6.</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">7.</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">8.</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.</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?

<span class="section-blue">(xi)</span> Any mental illness including anxiety, depression, stress or eating disorder, or have you attempted to harm yourself?

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)

<span class="section-blue">12. (ii)</span> Have you ever been treated for alcohol misuse, or advised/counselled to reduce your consumption of alcohol?

<span class="section-blue">(iii)</span> Have you taken cocaine, cannabis or any drugs other than for medicinal purposes within the last 10 years?

<span class="section-blue">(iv)</span> Have you ever tested positive for HIV/AIDS or are you awaiting the results of such a test?

<span class="section-blue">(v)</span> Have you ever tested positive for Hepatitis B or C or are you awaiting the results of such a test?

Family History

<span class="section-blue">13.</span> Have any of your parents, brothers or sisters ever had one or more of the following medical conditions at the ages specified:

<span class="section-blue"><u>Family member(s) aged 50 OR less</u></span>

<span class="section-blue">(i)</span> Breast or ovarian cancer?

<span class="section-blue">(ii)</span> Multiple Sclerosis, Motor Neurone disease or Parkinson’s disease?