Mortgage Protection 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.

All of the information you provide in the Personal Information Form must be provided honestly and with reasonable care
Data Capture Form
Title*
First Name*
Surname*
Where do you want your post to go?*
Your correspondence address
Date of Birth*
Date of Birth
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*
Where do you want your post to go?*
Date of Birth*
Date of Birth
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

All of the information you provide in the Personal Information Form must be provided honestly and with reasonable care

Data Capture Form

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 answer honestly and with reasonable care (See more details.)

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> Does your occupation involve any of the following: working externally at heights greater than 40 feet/12 metres † , offshore in oil, gas or fishing industries underground, handling explosives, flying, diving or are you in the armed forces?

<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 2 years? (Travel to UK, 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 pastimes such as motor racing, diving, private aviation or flying, mountaineering or off piste snow sports?

<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*, including less advanced early or in situ cancer, tumour, leukaemia, hodgkin’s disease, lymphoma or any cyst or tumour in the brain or spine?

<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, Transient Ischaemic Attack (TIA), Mini Stroke 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 or Haemochromatosis or clotting disorders?

<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">(x)</span> Diabetes or raised blood sugars or sugar in the urine, thyroid disorders* or any hormone abnormalities?

<span class="section-blue">(xi)</span> Any mental illness that required hospitalisation or inpatient treatment including psychosis, schizophrenia, bipolar disorder, an eating disorder or have you ever self-harmed or attempted suicide?*

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> Have you required attendance with a GP, Doctor or any mental health service for any of the following: anxiety, depression, low mood, stress or any mental health issue including addiction?*

<span class="section-blue">(ii)</span> Chronic fatigue syndrome or fibromyalgia or myalgic encephalomyelitis (ME), long covid, fatigue or persistent tiredness?

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

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

<span class="section-blue">(v)</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">(vi)</span> Ulcers or any disorder of the oesophagus, stomach, intestine, pancreas, bowel, bladder or urinary system including blood or protein in the urine?

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

<span class="section-blue">(viii)</span> ) Blurred or double vision, or any disorder affecting the eye (and not wholly corrected by spectacles or contact lenses), ear, nose, or throat?

<span class="section-blue">(ix)</span> Arthritis or joint disorders, gout, back, neck or muscular disorder?

<span class="section-blue">(x)</span> Male Lives - Prostate or any other urinary disorders. Female Lives - Abnormal mammogram, abnormal cervical smear or any other gynecological or urinary disorder?

<span class="section-blue">(xi)</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">(xii)</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">(xiii)</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 ever been treated for alcohol misuse, or advised/ counselled to reduce your consumption of alcohol?

<span class="section-blue">12. (ii)</span> Have you taken cocaine, cannabis, heroin, anabolic steroids or any drugs other than for medicinal purposes within the last 10 years?

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

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

<span class="section-blue">(v)</span> In the past five years have you been accepted with special terms, postponed or declined by Zurich Life or any other insurance company for Life cover, Serious Illness or Income Protection benefit?

<span class="section-blue">(vi)</span> Have you any medical condition which you know or suspect to be hereditary or for which you have received or advised to receive follow up or screening?

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 60 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?

<span class="section-blue">(iii)</span> Bowel or colon cancer?

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