Life . Accident . Illness . Disablement . Income . Medical . Funeral . KiwiSaver

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If you wish to apply for Life, and/or Accident, and /or Living Assurance,

You can complete the application form below, and:

print it, sign it and post it to us (address below), or
click submit and we will mail it to you for signature.
please also print and send a copy of your quote and a completed Direct Debit form, if you choose this payment method, with your completed application.

You can download this file and print it, complete the form, sign it and post it to us, or

You can call us on 0800 2NZlife (0800 269543) and we will initiate an application and send it to you for checking, completion and signature(s) with a Return Stamp Addressed Envelope.

To submit Joint Policies (2 lives - you and your partner), an application form must be completed for each and be signed by BOTH parties, on each application form, as Policy Owners.

If you wish to apply for any of the above and/or Total Permanent Disablement and/or Disability Income, download this file and print it, complete the form, sign it and post it to us.

Post to FreePost 207963, NZLife., P O Box 34778, Birkenhead, Auckland 0746

We suggest you read this FINE PRINT

Application Form

This application can only be used for Life applications up to $1 million and/or Accidental Death and /or Living Assurance applications up to $500,000 (inclusive of all existing Sovereign cover).

1. Life to be assured

Title:

Last Name:

First Name(s):

Previous Name:
(if changed)

Home address:

Mailing address:
(if different)

Email:

Home phone:

Business phone:

Mobile phone:

Date of birth:

/ /
(day/month/year)

Gender:

If you answer ‘yes’ to any of the questions below we may need to contact you for more information.

If we require further information to process your application quickly, can we use our Telephone Underwriting service?

If we require that you undergo medical tests, would you use our HealthScreen® service?

Would you like this policy to be grouped with another Sovereign policy for correspondence purposes?
If yes, policy number:

Children to be assured

Child 1		Child 2
Last Name:		Last Name:
First Name(s):		First Name(s):
Gender:		Gender:
Date of birth:	/ / (day/month/year)	Date of birth:	/ / (day/month/year)
Place of birth:		Place of birth:
Child 3		Child 4
Last Name:		Last Name:
First Name(s):		First Name(s):
Gender:		Gender:
Date of birth:	/ / (day/month/year)	Date of birth:	/ / (day/month/year)
Place of birth:		Place of birth:

2. Ownership

Ownership:

Same as Life Assured
Life Assured and secondary owner (fill out details below)
or seperate owner (fill out details below)

Title:

Last Name:

First Name(s):

Previous Name:
(if changed)

Home address:

Mailing address:
(if different)

Email:

Day time phone:

Date of birth:

/ /
(day/month/year)

Gender:

3. Benefit details

Life
To provide a lump sum in the event of death of the Life to be Assured.

Amount of cover: $

Accident
To provide a lump sum in the event of an accident.

Amount of cover: $

Critical Illness
To provide a lump sum in the event of a diagnosis of a specified condition of the Life to be Assured.

Amount of cover: $
Policy Type:

4. Personal statement

Occupation:

Industry:

In the course of this do you have to work:

at heights
underground
with explosives
with other hazards
please specify:

Please indicate your residency status:

Citizen/Permanent resident
Work Permit
Long term business visa
Other

Do you intend to live, work, or travel overseas in the next 12 months?

Live Work Travel
If you selected any of the above:
Where:
When:
How long:

Do you have, or are you currently applying for, any other life, income protection, trauma or health cover with Sovereign or any other company?

If 'Yes', give details below

Name of Company	Type of cover	Sum Insured	Date commenced	To be replaced?

Has any insurance you have, or you have applied for, ever been declined, deferred or modified including any loadings or exclusions?

if 'Yes' give details

Have you smoked in the last 12 months?

If 'Yes' what and how much do you smoke per day?

Height

(please specify cm or feet & inches)

Weight

(please specify kg or pounds)

Do you use, or have you ever used recreational and/or non-prescription drugs (except ‘over the counter’ medications)?

if 'Yes' give details

How many standard alcoholic drinks do you have per week on average?
(standard drink = 1 nip or 30ml spirits, 100ml wine, 300ml beer)

Do you engage, or intend to engage in, any of the following hazardous sports or activities:

Aviation
Motor racing
Motor boat racing
Diving
Mountaineering
Other - please specify:
please give details:

Have either of your parents or any of your brothers or sisters suffered from: diabetes, stroke, heart disease, high blood pressure, kidney disease, polycystic kidney, cancer (please specify type), Huntington’s chorea, mental illness, dementia, or any hereditary or familial disease before the age of 60?

if 'Yes' give details

Have you ever suffered from any of the following illnesses/conditions?

Stroke, spinal injury, neurological condition (e.g. MS)
Nervous disorder (e.g. depression)
Cancer, tumour, cyst, skin lesion/condition
Kidney, bladder, prostate, ovarian disorder
Diabetes, thyroid disorder, or any other glandular condition
HIV/AIDS
Stomach, pancreas, gall bladder, bowel, intestinal or oesophageal disorder
Blood disease (e.g. anaemia)
Respiratory disorders (e.g. asthma or emphysema)
Epilepsy
Speech impairment, loss of hearing, vision impairment
Liver disorder (e.g. hepatitis)
Disease or disorder of cervix, breast, uterus, fallopian tube or ovary.
Chest pain, heart disease or disorder (e.g. high blood pressure or high cholesterol)
Other (please specify)

Condition	Date of first symptoms	Date of last symptoms	Details (include treatment, test results, time off work, recurrence, current status)

Are you currently experiencing any health problems, or are you considering seeking medical advice, counselling, tests, treatment or an operation which is not disclosed above from any health professional?

if 'Yes' give details

Provide the details below of general practitioners, specialists or medical centres you have attended in the last five years.

Name of GP, specialist or clinic	Reason for visiting	Address	Years/months attended	Date of your last visit	Do they hold your medical records

Sovereign may require your medical notes from the last five years or longer, depending on the information you have disclosed. Your consent to Sovereign accessing these notes is set out in Section 5 (k).

Please use the space below to provide further details:

Payment details

Payment method

Direct debit
Credit/Debit Card
Use existing Sovereign direct debit

Premium amount

Deposit enclosed

Payment frequency

Weekly (for direct debit payments only)
Fortnightly
Monthly
Annually

Please specify date of first payment, e.g. 17th

IMPORTANT NOTICE: Your duty of disclosure

Before you enter into this contract of Insurance (‘Insurance’), you have a duty to disclose to Sovereign Assurance Company Limited (‘Sovereign’) every matter that is material to its decision concerning whether to accept the risk of the Insurance and, if so, on what terms. You have the same duty to disclose those matters to Sovereign before you apply to vary or reinstate the Insurance. If you fail to comply with your duty of disclosure to us, and we would not have issued the Insurance on the same terms if disclosure had been made, we may cancel or avoid the Insurance from inception.

I understand the importance of full disclosure of all information required in this application for insurance.

Validation:

Please help us distinguish between a real individual and spam robots by typing the 3rd word in the list below:
"hope beautiful kind flower wonderful"

Submit Application - the above application will be sent electronically and mailed to you for checking and signature.
Printable Application - an application suitable for printing will be produced for your signature and mailing (or if submitted to retain as a personal record)

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