Royal London Whole of Life Assurance Application

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As Ireland's leading life insurance broker, we specialise in comparing the rates and policies from the top five Irish life insurance providers and offering the very best value quotes to suit the individual needs of our clients. Our expertise lies in finding a suitable insurance plan for those with specific needs, be it a particular illness, occupation or claim history, we've got you covered in every sense!

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Royal London Whole of Life Assurance Application

WOL - Royal London 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

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 <span class="section-grey">(including electronic cigarettes)</span>

How many units of alcohol do you drink in a typical week? <span class="section-grey">one pint of beer or 175ml glass of wine = 2 units, one 25ml measure of spirits = 1 unit</span>

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. <span class="section-grey">Ignore holidays of up to a month</span>

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? <span class="section-grey">You do not need to disclose non‑hazardous team sports such as football, rugby or hurling</span>

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:

<span class="section-blue">(Q1)</span> Any form of cancer, tumour, lymphoma, Hodgkin’s disease, leukaemia, melanoma or any brain or spinal growth or cyst?

<span class="section-blue">(Q2)</span> Disease or disorder of the heart (including valves) or circulatory system, heart attack, angina cardiomyopathy, disease of the arteries or peripheral vascular disease?

<span class="section-blue">(Q3)</span> A stroke, transient ischaemic attack (TIA/mini-stroke), brain haemorrhage,aneurysm, brain injury or surgery to your blood vessels in the brain or neck?

<span class="section-blue">(Q4)</span> 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?

<span class="section-blue">(Q5)</span> 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?

<span class="section-blue">(Q6)</span> Diabetes, raised blood sugar or sugar in the urine, thyroid problems, goitre orglandular fever?

<span class="section-blue">(Q7)</span> A positive test for HIV/AIDS or Hepatitis B or C, or are you awaiting the results of such a test? <i class="section-grey">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.</i>

<span class="section-blue">Apart from anything you have already told us about, <u>during the last 5 years</u> have you had any of the following:</span>

<span class="section-blue">(Q8)</span> Raised blood pressure, raised cholesterol, chest pain or irregular heart beat?

<span class="section-blue">(Q9)</span> Numbness, pins and needles, optic neuritis, double/blurred vision, tremor, tingling,muscle weakness, loss or reduced power in limbs, or persistent tiredness or fatigue? <i class="section-grey">Please answer ‘yes’ whether seen by a doctor or not.</i>

Health contd.

<span class="section-blue">(Q10)</span> Any form of arthritis, gout, joint or ligament pain or neck, back, spine/muscle pain?

<span class="section-blue">(Q11)</span> Any disorder affecting your ears or hearing, or your eyes or vision that is not whollyu0003 corrected by spectacles or lenses?

<span class="section-blue">(Q12)</span> A tumour, lump, cyst, polyp, growth or a mole or naevus that has bled, changed inu0003 appearance or become painful? <i class="section-grey">Please answer ‘yes’ whether seen by a doctor or not.</i>

<span class="section-blue">(Q13)</span> Asthma, bronchitis, sarcoidosis, emphysema or any other disorder affecting your u0003lungs or breathing?

<span class="section-blue">(Q14)</span> Any disorder of the digestive system, liver, stomach, pancreas or bowel (including u0003any ulcer, hepatitis, colitis, Crohn’s disease or Barrett’s oesophagus)?

<span class="section-blue">(Q15)</span> Haemochromatosis , anaemia, vitamin b12 deficiency, clotting disorders or any otheru0003 blood disorders?

<span class="section-blue">(Q16)</span> Any disorder of the kidney, bladder or prostate, including blood or protein in the u0003urine or raised PSA (Prostate Specific Antigen)?

<span class="section-blue">Apart from anything you have already told us about, <u>during the last 3 years</u> have you:</span>

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 u0003cover declined, postponed or had special terms applied to it?

If you are currently applying for Specified Serious Illness cover do you intend taking out u0003total 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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