protection
Protection Cover
Application Form
Application No.
1. Insureds
1st Life to be insured
2nd Life to be insured (if applicable)
Forename(s)
Forename(s)
Title
Surname
Title
Surname
Present address
Present address
Marital Status
Marital Status
Daytime telephone number
Daytime telephone number
Alternative telephone number
Alternative telephone number
Email address
Email address
Occupation
Occupation
(describe type of business and nature of duties)
(describe type of business and nature of duties)
Date of birth (evidence required)
Date of birth
(evidence required)
2. Grantee(s) if different
Full name(s) and address(es) of
person(s) who are effecting this policy
Relationship to Life/Lives to be insured
or details of insurable interest
2a.
Purpose of cover
3. Your Protection Cover Requirements (For full details on all cover types please consult our Protection Cover brochure).
Cover Details
Single Life
Term
Monthly Direct Debit
Joint Life
Years
Yearly Direct Debit
Dual Life
Joint Life 2nd Death
(not available for
Mortgage Protection Policies)
(available for Guaranteed
Whole of Life only)
Premium quoted
1. Mortgage Cover (Reducing)
Please select one of the following covers
Sum Assured
A Mortgage Protection Life Cover
B
€
Mortgage Protection Life Cover with
Accelerated Serious Illness
€
If B selected, please select Hospitalisation Cover
Yes
No
If yes please specify amount (€50/€100/€150)
€
2. Life and/or Serious Illness Cover (Level)
Please select from the following covers
1st Life Sum Assured
2nd Life Sum Assured
(if dual life only)
A. Life Cover (Level and Convertible Term Assurance)
€
€
B. Stand Alone Serious Illness Cover*
€
€
C. Accelerated Serious Illness Cover*
€
€
If B or C selected, please select Surgical Cash
Yes
No
Yes
No
Hospitalisation Cover
Yes
No
Yes
No
€
If yes, please specify amount (€50/€100/€150)
€
If A, B or C selected, please select Indexation
Yes
No
Conversion Option
Yes
No
1st Life Sum Assured
€
D. Guaranteed Whole of Life Cover
Guaranteed Increasing Benefit Option
If the policy is to be written in trust please select trust type
Yes
Sec 72/Sec 60
2nd Life Sum Assured
€
No
General Trust
* Applicants for Serious Illness Cover should refer to the ‘Standard Restrictions’ section in their Protection Cover brochure
for details of the restrictions, conditions and exclusions that apply to this cover.
Hibernian’s Requirements,
Please complete Parts 1 and 2
Please note carefully
Failure to disclose all material facts could render your contract void. Material facts are those, which an insurer
would regard as likely to influence the assessment and acceptance of an application for insurance.
If you are in any doubt as to whether certain facts are material, such facts should be disclosed. Any changes to
the answers given before the cover comes into force must be notified to Hibernian Life & Pensions Limited.
In accordance with the Disability Act 2005, you should not disclose the results of any genetic tests undertaken.
Part 1 Personal statements to be answered by the lives to be insured (Please answer carefully giving full details)
1st Life to be insured
2nd Life to be insured
Name and address of your current Medical Attendant or family Doctor and any other specialist you may have attended.
If you have changed your Doctor in the last 18 months, please give the name and address of your previous Doctor.
Replies 2nd life
Replies 1st life
1
(a) What is your height?
ft
ins
ft
ins
or mtrs
cms
mtrs
cms
st
lbs
st
lbs
(b) What is your weight?
or
2. Have you smoked any form of tobacco in the past year?
If “Yes” please state consumption and frequency:
1st Life
kilos
Yes
kilos
No
Yes
No
Cigarettes
Cigars
Pipe Tobacco (ozs)
daily
weekly
2nd Life Cigarettes
Cigars
Pipe Tobacco (ozs)
daily
weekly
3. How much alcohol do you currently drink (units)?
Please quantify e.g. 1 short or a glass of wine = 1 unit,
1 pint = 2 units
weekly
weekly
Part 2 Personal statements to be answered by the lives to be insured
(If any questions are answered “Yes”, please give full details and ask your financial adviser
for the relevant Medical or Hazardous Pursuits Questionnaire which must
be completed and returned with your application form)
Replies 1st life
1. Have you made a previous application for life, serious illness, income
protection or premium protection to Hibernian Life & Pensions?
Yes
2. Are you currently proposing or have you proposed in the
last 12 months for life, serious illness, income
protection or premium protection with any other company?
If yes please state which companies and the sum(s)
insured proposed.
3. Has a proposal on your life ever been postponed, declined or
accepted on special terms? Please provide full details of the
companies and dates.
4. (a) Do you engage or intend to engage in any hazardous pursuits
or occupations? (e.g. aviation, working at heights, climbing,
diving or motor sports etc)
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
No
Yes
No
(b) Have you in the last 5 years, are you currently or do you intend to
in the future, travel, live or work abroad ? (Travel to or residency Yes
in the following can be ignored: United Kingdom, Portugal, Spain,
France, Belgium, Holland, Germany, Switzerland, Austria, Italy,
Greece, Denmark, Norway, Sweden, Finland, Cyprus, Malta,
Luxembourg, North America, Australia and New Zealand).
If yes please provide full details.
Replies 2nd life
Part 2 Personal statements to be answered by the lives to be insured
5. Have you ever had or been advised to have any medical attention, operations,
x-rays, tests, investigations or treatment for any of the following:
Replies 1st life
Replies 2nd life
(a)
Disease of the heart, circulatory system, heart attack, angina,
chest pain, stroke, blood pressure or raised cholesterol?
Yes
No
Yes
No
(b)
Diabetes?
Yes
No
Yes
No
(c)
Mole that has changed in size, colour or bled, lump, growth,
tumour or cancer?
Yes
No
Yes
No
(d)
Stomach, bowel complaint, hernia, irritable bowel syndrome,
diverticulitis, ulcerative colitis or Crohn’s disease?
Yes
No
Yes
No
(e)
Liver, abnormal liver function or liver function tests?
Yes
No
Yes
No
(f)
Asthma, bronchitis, sarcoidosis or any other respiratory disorder?
Yes
No
Yes
No
(g)
Depression, anxiety, mental illness or work related stress?
Yes
No
Yes
No
(h)
Multiple sclerosis, any other neurological disorder, double
vision or any other disorder of the eyes (other than the
wearing of prescribed glasses or contact lenses)?
Yes
No
Yes
No
(i)
Numbness, loss of feeling or tingling of the limbs or face,
or temporary loss of muscle power?
Yes
No
Yes
No
(j)
Disease or disorder of the ears or hearing?
Yes
No
Yes
No
(k)
Epilepsy, seizure or vertigo?
Yes
No
Yes
No
(l)
Kidney or bladder disorder?
Yes
No
Yes
No
(m) Arthritis, rheumatism, joint, muscle or bone disorders,
backache, back injury, whiplash or other physical disability?
Yes
No
Yes
No
(n)
Yes
No
Yes
No
6. Are you now or have you recently been prescribed drugs,
medication, advised medically to diet or are you currently
undergoing any other form of treatment?
Yes
No
Yes
No
7. Have you ever been treated for alcoholic habits, had
in-patient treatment for alcohol abuse, been advised
medically to reduce your alcohol consumption or cease
alcohol completely or taken drugs for other
than medical reasons?
Yes
No
Yes
No
8. During the last 5 years have you had any illness or injury
requiring medical attention?
(Colds, influenza and minor injuries may be excluded).
Yes
No
Yes
No
9. Have you been tested positive for HIV/AIDS or Hepatitis B or
C or have you been tested/treated for other sexually transmitted
diseases or are you awaiting the result of any such tests?
For extra confidentiality, these details can be sent to the
Chief Medical Officer at: Hibernian Head Office, One Park Place,
Hatch Street, Dublin 2.
If Yes, please provide details
Yes
No
Yes
No
Have you ever had any other illness or injury requiring
medical attention, surgical operation or special investigation
by a consultant or at a hospital?
(Colds, influenza and minor injuries may be excluded).
10. Has any one of your natural parents, brothers or sisters
whether living or dead ever suffered from diabetes, stroke,
heart or kidney disease, cancer, or any hereditary disease
or disorder, (such as Huntington’s chorea, polycystic kidney
disease) before 60? If Yes, give full details.
Yes
No
Yes
No
Replies 1st Life
Relation
Disease/Disorder (If Cancer, state site)
Age at Diagnosis
Replies 2nd Life
Relation
Disease/Disorder (If Cancer, state site)
Age at Diagnosis
11. Does the amount of total cover (Life and Serious Illness)
that you already hold, including any cover that is currently
proposed or contemplated, exceed €15,000,000?
Types of cover include, but are not limited to, any personal cover,
mortgage cover, (commercial or personal) business cover
and death in service cover.
Yes
No
Yes
No
If you have answered yes to any of questions 1-11, please give full details, using a separate sheet if necessary.
Declarations
(must be completed for all Covers)
I/We, the life/lives to be insured, declare that I/we am/are in good health and I/we irrevocably authorise and request any doctor
or other person who may be in possession of, or hereafter acquire, any information regarding my/our health up to the present
time to disclose such information (with the exception of the results of genetic tests) to Hibernian Life & Pensions and I/we agree
that this authority shall remain in force after my/our death as well as prior thereto. I/We consent to Hibernian Life & Pensions
seeking information from any insurance company to which an application on my/our life/lives or for accident or sickness has been
made and I/we authorise the giving of such information (with the exception of the results of genetic tests). I/we declare that the
answers to the questions on the application whether in my/our handwriting or written by another at my/our dictation are strictly
true and complete and that this application and Declaration together with any statements made by the life/lives to be insured to
the Medical Examiner acting for Hibernian Life & Pensions, or any other insurance company, shall be the basis of the contract and
I/we understand that if a premium is tendered or a direct debit order signed no binding contract is created until Hibernian Life &
Pensions assumes risk.
Hibernian Life & Pensions will keep the information you provide about yourself and about third parties confidential. We may use
it to provide and administer financial services products provided by us and sometimes with our affiliates and/or commercial partners.
We may pass the information, in confidence, for these purposes to agents or service providers we have appointed, regulatory
organisations, other insurance and financial services companies (directly or via a central register), other Aviva group companies and
as required by law. We will process this information and store it on our computer and manual record systems.
If you would like a copy of the details we hold about you, please write to the Compliance Manager, Hibernian Life & Pensions,
One Park Place, Hatch Street, Dublin 2. Please enclose the correct fee (€5). You also have the right to correct any errors in the
information held about you, block certain uses or object to the processing of your personal data.
Some of the questions on this form ask for details about your health and lifestyle. This information is important for underwriting
purposes and will remain confidential. By signing the declaration below, you are giving us permission to process these details for
the above purposes, including checking with third parties or accessing State or other official records to verify whether the details
you have given are accurate and complete. By signing below, you are confirming that you understand why we asked for this
information and what we will use it for. ONLY SIGN THE FOLLOWING DECLARATION IF YOU FULLY UNDERSTAND, AND HAVE
MET, ALL OF THE ABOVE REQUIREMENTS.
We would like to use the details to provide you with information about other products and services either from us or other
Aviva group companies, or products or services which any member of the Aviva group has arranged for you with a third party.
If you choose not to receive this information, this will not affect any of the services we provide to you, now or in the future.
Please tick here
if you wish to receive information on other products, services and special offers.
If your application for insurance is declined or accepted subject to special terms then that fact may be noted on a registry administered by the Irish Insurance Federation and may be shared with other offices as a protection against non disclosure of material facts.
Any changes to the answers given, before the policy comes into force, must be notified to Hibernian Life & Pensions.
Telephone calls may be recorded for quality and training purposes.
Please sign - Do not use block capitals
1st life to be insured
2nd life to be insured
x
x
Signature of Grantee(s) if different
Date
Date
x
Date
In the case of a corporate grantee state name of company that authorised signatory is signing
for and on behalf of
Please note carefully
Any change in occupation or residence must be notified to Hibernian Life & Pensions Limited during the policy term. This is a legal
document and forms part of the basis of the contract. All sections must be fully completed and any alterations initialled by the
signatory/signatories. Failure to provide true and complete information may render the contract void. A copy of the completed application
form is available on written request by or on behalf of the proposer(s), and a copy of the policy conditions is available on request.
Please note: The policy number of the policy being replaced must be provided.
NOTE: PLEASE ENSURE FOLLOWING DECLARATION IS SIGNED BY CLIENT AND INTERMEDIARY.
WARNING: If you propose to take out this policy in complete or partial replacement of an existing policy, please take special care to
satisfy yourself that this policy meets your needs. In particular, please make sure that you are aware of the financial consequences of
replacing your existing policy. If you are in doubt about this, please contact your insurer or insurance intermediary.
Ref. Policy Number of Policies to be cancelled:
Declaration of Insurer or Intermediary
I hereby declare that in accordance with Regulation (1) of the Life Assurance (Provision of Information) Regulations, 2001,
the applicant has been provided with the information specified in Schedule 1 to those Regulations and that I have advised
the client as to the financial consequences of replacing an existing policy with this policy by cancellation or reduction and of
possible financial loss as a result of such replacement.
Name of Insurer or Insurance Intermediary
Signed
Date
LARC No.
Declaration of Client(s)
I /We confirm that I/We have received in writing the information specified in the above declaration.
Signature: 1st life to be insured
Date:
Signature: 2nd life to be insured
x
x
Date:
For Financial Adviser use only
Please ensure all relevant questions are answered before submitting the application form.
1. Name & Address
2. Agency No.
3. Name of Financial Adviser/Salesperson
5. Financial Adviser/Salesperson Reg. No. (LARC)
4. Financial Adviser’s/Salesperson’s Email address
6. Start Date
Please note: The policy number of the policy being replaced must be provided (see declaration).
If it is not provided the existing policy will remain in force
For office use only
1. Consultant
2. Branch
Date
3. Vetted by
Date
Direct Debit Mandate
Please complete parts A to E to instruct your bank to make payments directly from
your account.
Your instructions to your bank. I/We instruct you, to pay direct debits from my/our
account at the request of Hibernian Life & Pensions Limited.
The amounts are variable and may be debited on various dates.
I/We understand that Hibernian Life & Pensions Limited may change the amounts
and dates only after giving me prior notice. I/We will inform the bank in writing or
Hibernian Life & Pensions Limited if I/we wish to cancel this instruction.
I/We understand that if any Direct Debit is paid which breaks the terms of this
instruction, the bank will make a refund.
A. Please complete full postal address of your Bank Branch
Hibernian Life & Pensions Limited
ID number 99-29-50
Reference number office use only
B. Account name
C. Account number
D. Bank sort code
To: The Manager
E. Signature(s)
Banks may refuse to accept instructions to pay Direct Debits from some types of
accounts, usually savings or deposit accounts. If in doubt check with your Bank.
Hibernian Life & Pensions Limited may amalgamate Direct Debits under this mandate
with any other mandates payable by Direct Debit which may be due to them within
the same calendar month under other mandates expressed in their favour and signed
by me/us.
x
x
Date
Application Number
2.04.06.07A
Hibernian Life & Pensions Limited Registered in Ireland No. 252737 Registered Office One Park Place, Hatch Street, Dublin 2.
Member of the Irish Insurance Federation
Hibernian Life & Pensions Limited is regulated by the Financial Regulator
Hibernian Life & Pensions Limited is a subsidiary of Hibernian Life Holdings Limited, a joint venture company between Hibernian Group Plc and Allied Irish Banks, p.l.c.
Life & Pensions
One Park Place, Hatch Street, Dublin 2. Phone (01) 898 7000 Fax (01) 898 7329
www.hibernian.ie
Telephone calls may be recorded for quality and training purposes.