PROTECTION
PERSONAL INCOME PROTECTION
APPLICATION
Adviser’s Name:
Agency No.:
Please tick (3) where appropriate
Please ensure that all questions are answered to prevent any delay in the assessment of your application. This application form
along with a recorded Tele-interview will form the basis of your contract. The person to be covered will be contacted by telephone by
our Tele-interview provider to complete the application in full. For further details on this procedure please refer to the
“Tele-interview Explained” section of this form.
1. Person to be covered
Title:
Mr
Mrs
Ms
Other
Surname:
First name:
Address:
D
D
M
M
Y
Y
Date of Birth:
Y
Y
Sex:
Male
Female
PPS Number:
Occupation:
Please ensure you check the Occupational Guide to see if the occupation is eligible for Income Protection.
Smoker:
Yes
No
2. Arranging your Tele-interview
To speed up the processing of your application we strongly recommend you arrange the Tele-interview prior to submitting the
application to us as this will avoid unnecessary delays in processing your application. This Tele-interview will be recorded.
Contact Number(s) for Tele-interview:
Mobile:
Preferred Contact Time for Tele-interview:
Home:
Morning
Afternoon
Work:
Evening
You may contact our Tele-interview provider on freephone 1800 805395 to arrange a suitable time for your Tele-interview. You will be
given a reference number to record in the field below:
Tele-interview reference number:
If you are not in a position to arrange a Tele-interview at this stage we will pass on your personal details to our Tele-interview
provider who will then contact you to arrange a suitable appointment. Please note that this will likely result in your application taking
longer to process.
Page 1 of 8
3. Cover details
Income Protection Amount*: E
*75% of gross annual earned income less state illness benefit if applicable and any income that will continue in the event
of a disability, subject to an overall max of E175,000 p.a.
†Between 55 and 65. Please ensure the expiry age is eligible for the Expiry Age†:
person to be covered’s occupation type
Deferred Period: 8 wks
13 wks
Indexation:
Yes
No
Confirmed Income Option††:Yes
No
††If
26 wks
52 wks
this option is chosen, proof of income will be required before the policy goes on risk.
4. Payment details
Note: In addition to the Premium, a Government levy (currently 1% of the premium paid) will be
collected on each premium due date
Premium:
D
D
M
M
Y
Y
Y
Y
Preferred Policy Start Date:
Frequency:
Every Year
As soon as possible
Every 6 months
If you are paying yearly premiums do you wish to pay by cheque?
Every 3 months
To be advised
Every month
or Direct Debit?
5. Collection of underwriting information
If you proceed with this application, the resulting policy will be based on the information you tell us
- in this application form,
- in any questionnaire completed by you or by a medical examiner and signed by you and
- in any Tele-interview you complete.
If you complete a Tele-interview it will be recorded and you will be sent a transcript of the Tele-interview for you to check and keep for
your records.
Failure to disclose all material facts, in this application, any questionnaire signed by you and in any Tele-interview you complete, could
render your contract void. Material facts are those, which an insurer would regard as likely to influence the assessment and acceptance
of a proposal for insurance. If you are in doubt as to whether certain facts are material, such facts should be disclosed.
We may not necessarily contact your doctor(s). Even if we do, you must still disclose all material facts. We may ask you to have a medical
examination with your own doctor or an independent doctor. If this is required we will notify you in writing.
Material Facts Exemption in Relation to Genetic Tests
You are not required to disclose any genetic tests you may have had and we will not have regard to any genetic tests which may come into
our possession. You are however required to provide us with full details (other than genetic tests) in answer to all the health and lifestyle
questions including full medical details about your family history.
Doctor Details
1. a) Please give the name and address of your usual doctor?
b) Have you changed your doctor in the last year?
Yes
If Yes, please give the name and address of your previous doctor
No
Page 2 of 8
6. Employment and financial details
1. Have you recently submitted or do you intend to submit an application for life cover and or critical illness cover to New Ireland Assurance?
If Yes, please advise the following:
Name of Insurance Company:
Annual Benefit Amount:
Will this cover be cancelled on issue of this policy
If Yes, please state for how many weeks this income is payable: Yes
No
wks
Employed
Self Employed
Share Holding Director
2
a) If you are Employed, please state your annual gross salary* in the last tax year
* Annual personal earned income before tax in the last year including any regular overtime, commission & bonuses
b) If you are Self Employed or a Share Holding Director, please state the following:
■ Your annual gross income* in the last 3 consecutive tax years
*Annual Personal Earned Income before tax in the last complete tax year
No
No
Yes
4. In relation to your employment status, are you:
Yes
2
3. Would you receive an income from your employment if you were unable to work due to an illness or injury?
No
If yes, please give details.
2. Do you currently have existing Income Protection cover with New Ireland Assurance or any other Life Office?
Yes
20
2
20
2
■ Number of employees working for you (including sub contractors):
20
2
if applicable
If the Confirmed Income Option is chosen the following proof of income is required:
■ Employed
A copy of the three previous months salary slips and a copy of the previous years P60.
■ Self Employed
A copy of the three previous years Notice of Assessments along with a copy of related Company Accounts.
■ Share Holding Directors
A copy of the three previous years P60s/Notice of Assessments along with a copy of related Company Accounts.
If you are self- employed or have been operating your own business for less than one year then your requested benefit level may be
reduced or you may not be eligible for the Confirmed Income Option.
Important Note
The Confirmed Income Option is only available when satisfactory financial evidence is provided before the policy goes on risk.
Page 3 of 8
7. Declaration of receipt of disclosure information and policy replacement
n Please ensure you complete this section before signing this proposal for assurance.
n Declaration under Regulation 6(3) of the Life Assurance (Provision of Information) Regulations, 2001.
n
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.
Declaration of Insurer or Intermediary
I hereby declare that in accordance with Regulation 6(1) of the Life Assurance (Provision of Information) Regulations, 2001, the Policy Owner, as stated
in Section 1 of the Application, have 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.
@
Insurer/
Intermediary
Signature:
D
D
M
M
Y
Y
Y
Y
D
D
M
M
Y
Y
Y
Y
Date:
Person to be covered
I confirm that I have received in writing the information specified in the above declaration.
@
Signature:
Date:
8. Declaration/Data Protection Consent
A. I declare:
1. that in this application I have disclosed all material facts; and
2. I understand that in any questionnaire signed by me and in the Tele-interview I must disclose all material facts; and
3. that to the best of my knowledge, all statements made on this application form whether in my hand – writing or dictated by me
are true and complete.
B. I consent to you seeking:
1. any medical information now or in the event of a claim from any doctor who has at any time attended me;
2. any information from any life insurer to which a proposal has been made on my life; and I authorise the giving of such
information to you.
C. I agree to the following:
1.all of the statements made on this application form and other statements made by me in writing and/or in the Tele-interview in
connection with this application shall form the basis of the contract between you and me.
D. I understand that:
1. the proposed contract will not come into force until New Ireland Assurance has accepted me for cover and issued a policy
document and I have made the first premium payment;
and
2. if I do not pay the first premium, the contract will not be valid even if you send me a policy document.
3. any changes to the statements in
- this application,
- any questionnaire signed by me and
-any Tele-interview I complete before the proposed contract comes into force, must be notified in writing to
New Ireland Assurance.
4.if my proposal is declined or if I am offered insurance on special terms then, whether or not my application proceeds, this fact
will be noted on a central registry, administered by the Irish Insurance Federation, and may be shared with other insurance
companies as a protection against non-disclosure of material facts. I understand that in the event of my application not
proceeding, information provided in connection with my application will be retained by New Ireland Assurance for a period of six
years to facilitate any future application by me and as a protection against non-disclosure of material facts.
E. I confirm that I:
have had the meaning of disability, the benefit available under the policy and the reductions that will be applied to the benefit
where there are payments from other sources fully explained to me and that I understand and accept these provisions.
Page 4 of 8
8. Declaration/Data Protection Consent (continued)
I understand and consent that New Ireland and its duly authorised agents may hold and use the Information on computer file, in any
other dematerialised form or in written hard copy on its own behalf and may use or pass the Information to third parties for regulatory,
administration, customer care and service purposes.
n
n
I agree that New Ireland or a duly authorised agent of New Ireland may contact me in person, by phone,
or by letter if it considers that my financial planning arrangements need to be reviewed or my level of
cover needs to be revised.
I agree that the Information may be held and used by New Ireland for Marketing purposes.
Yes
No
Yes
No
I understand that I may write to advise New Ireland to cease to hold and use the Information for Marketing purposes at any time.
“Information” means any information including medical and non-medical given by me or on my behalf in connection with this
application or any further information which may be given at a later stage either in writing, by email, at a meeting or over the
telephone.
“Marketing” means direct marketing and cross-selling of the services and/or products provided by New Ireland or arranged by New
Ireland with a third party.
@
D
Person to
be covered:
D
M
M
Y
Y
Y
Y
Date:
Page 5 of 8
9. Tele-interview explained
Your Guide to Tele-interviews:
Thank you for your application for insurance with New Ireland Assurance. To process your application as smoothly and as quickly as
possible, we will arrange for a specialist nurse to telephone you and interview you about your health.
You do not have to do anything within the next few days. Our specialist provider will contact you by telephone to arrange the interview.
If you are not free to answer the questions when called, he/she will be happy to arrange a more suitable time.
Please note that all calls will be recorded.
What is a Tele-interview?
A Tele-interview is an interview conducted over the telephone by a nurse. The interview will gather details of your health and medical
history. All Tele-interviewers are experienced nurses, so you can rest assured that the interview will be conducted in a confidential
and professional manner.
A series of questions about your health, lifestyle and your immediate family medical history will be asked, and the interview takes at
least 30 minutes.
Why are you being interviewed?
To offer New Ireland Assurance customers the best possible terms for their insurance, it is essential that a clear understanding of
your present state of health and any conditions you may have suffered in the past is obtained. This information is used in our risk
assessment, prior to considering your insurance cover. Please accept our assurances that the information you provide will be treated
in the strictest confidence, and used only in the assessment of your application or in the event of a claim
What do I need to prepare?
To prepare for your interview, please take some time to gather the following information and have this to hand when you receive
the call:
■ Any medication you are currently taking (including the name and dosage).
■ Any past or present medical condition suffered, (other than very minor aliments such as the common cold.)
■Any tests or investigations, e.g. blood pressure, cholesterol tests. It would be helpful if you phone your GP or whoever did these
tests, to get the results.
■Details of any serious condition, such as cancer, heart attack, stroke, suffered by a member of your immediate family
(your mother, father, brothers or sisters, or half brothers and sisters.)
■ We will ask for your height and weight. If you do not know your weight, please try and weigh yourself prior to the interview.
If you are not sure whether something is important, then it is best to mention it. The nurse will assist you with any questions you
may have.
How will you be contacted?
If you have given us preferred times, then we will try and reach you at these times. If you are called at an inconvenient moment, please
ask to be called again at a more suitable time.
If you have not been contacted within three days, or you have been away or out of touch, please phone your Financial Adviser.
The nurses are able to undertake interviews from 9am to 9pm Monday to Thursday,
9am to 5pm on Fridays,
10am to 4pm on Saturdays.
It is important that you are able to speak freely and have the time to spare to complete the interview. It is better not to conduct the
interview over a mobile phone, but if this is your preference, we will do so. We will not complete an interview if you are driving.
Unfortunately, your application for insurance cannot be processed until the interview has taken place.
Why is it important I provide the right information?
The recorded interview and your application form shall form the basis of the contract between you and New Ireland Assurance. All the
questions should be answered fully and honestly, as failure to do so could invalidate your policy and any future claims.
What happens after the interview?
You will be sent a copy of the interview report for you to check, ensuring that the information is complete and accurate. Although a
little time consuming it is in your best interest to undertake this task with all due care. If you need to change or add anything to the
interview report, then please make any such amendment, then sign and return to us, in the freepost envelope provided.
Should you have any general questions relating to your application, New Ireland Assurance can be contacted on Tel 1850 200 318*,
Monday to Friday, 8.00am to 6.00pm. To monitor the ongoing quality of the service we provide, your call may be recorded.
*Calls are charged at local rates. For quality and training purposes incoming and outgoing calls may be recorded. Call charges may
vary depending on your service provider.
Page 6 of 8
10.Direct debit mandate
nNote: Instructions can only be accepted to charge
direct debit to a Current or similar account.
Bank Sort Code:
To the Manager:
Name of Account
to be debited:
Bank
-
Bank Account No.:
Address
Comhlucht Na hÉireann um Árachas c.p.t.
New Ireland Assurance Company plc.
11-12 Dawson Street, Dublin 2.
-
I/We authorise you
until further notice
in writing to charge
to my/our account
with you unspecified
amounts which may be
debited thereto at the
instance of New Ireland
Assurance Company plc.
by direct debit.
@
Signed:
Date:
D
D
M
M
Y
Y
Y
Y
Policy No.:
/
Originator’s No.:
Originator’s Ref.:
9
9
9
3
6
8
Page 7 of 8
New Ireland Assurance Company plc.,
11-12 Dawson Street, Dublin 2.
T: (01) 617 2000 F: (01) 617 2800.
E: [email protected] W: www.newireland.ie
A Member of New Ireland Group.
New Ireland Assurance Company plc is regulated by the Financial Regulator.
301450 V1/08/09
Page 8 of 8