Get a Quote Prefer to talk to someone about your application? Call our friendly team at OneLife Insure 01 539 0410 1 Policy Details2 Cover Details3 About you4 About your lifestyle5 Medical6 Medical7 Doctor Details8 Confirmation Policy*Select a Policy TypeLife InsuranceSpecified IllnessMortgage ProtectionSingle or Joint* Single JointEmail* Phone Number*1st PersonName* First Last Date of Birth* DD MM YYYY Gender* Male FemaleSmoker?* Smoker Non-SmokerHow much Life Cover do you require?*How much Specified Illness Cover do you require?*How much Mortgage Protection Cover do you require?*2nd PersonName (2nd Person)* First Last Date of Birth (2nd Person)* DD MM YYYY Gender (2nd Person)* Male FemaleSmoker? (2nd Person)* Smoker Non-SmokerHow much Life Cover do you require? (2nd Person)*How much Specified Illness Cover do you require? (2nd Person)*How much Mortgage Protection Cover do you require? (2nd Person)*TermHow long do you need your policy to last (in years)?*CONFIRM DETAILS & PROCEED?GET A QUOTE Choose from the available cover options*Your results from OneLife Insure* The full application process should only take 5-10 minutes (you can also save and return to it). You must answer all of the questions yourself - you should not complete this application on behalf of someone else. It is important that you answer all of the questions fully, honestly and to the best of your knowledge. Otherwise, you risk your insurance being cancelled or risk a future claim being rejected or reduced.Details Person 1What is your marital status?*SingleMarriedCohabitingSeparatedDivorcedWidowedWhat is your country of birth?* AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Would you prefer to give your height in feet and inches or in centimetres?*Feet and InchesCentimetresWhat is your height?*4' 0"4' 1"4' 2"4' 3"4' 4"4' 5"4' 6"4' 7"4' 8"4' 9"4' 10"4' 11"5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7' 0"What is your height?*121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218Would you prefer to give your weight in pounds or kilograms?*Stone and PoundsKilogramsWhat is your weight (stone)?*What is your weight (lbs)?*What is your weight (kg)?*Which of the following describes you?*I am an occasional smoker or have smoked in the last 12 monthsI have used nicotine replacement products including e-cigarettes in the last 12 monthsI have NOT smoked or used nicotine replacement products including e-cigarettes in the last 12 monthsI have never smokedWhat is your main occupation*What is your employment status?EmployeeSelf EmployedHomemakerStudentRetiredUnemployedHave any of your biological parents, brothers or sisters been diagnosed or died with any of the following before the age of 60?* Heart Attack, Angina or Stroke Cancer (including leukaemia or lymphoma) Multiple Sclerosis Muscular Dystrophy, Motor Neurone Disease or Huntington's Disease Cardiomyopathy Polycystic Kidney Disease Familial Colon Polyps Diabetes Alzheimer's Disease or Parkinson's Disease Haemochromatosis None of the above If yes, please provide details including when the condition was diagnosed*Details Person 2What is your marital status?*SingleMarriedCohabitingSeparatedDivorcedWidowedWhat is your country of birth?* AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Would you prefer to give your height in feet and inches or in centimetres?*Feet and InchesCentimetresWhat is your height?*4' 0"4' 1"4' 2"4' 3"4' 4"4' 5"4' 6"4' 7"4' 8"4' 9"4' 10"4' 11"5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7' 0"What is your height?*121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218Which of the following describes you?*I am an occasional smoker or have smoked in the last 12 monthsI have used nicotine replacement products including e-cigarettes in the last 12 monthsI have NOT smoked or used nicotine replacement products including e-cigarettes in the last 12 monthsI have never smokedWhat is your main occupation*What is your employment status?EmployeeSelf EmployedHomemakerStudentRetiredUnemployedHave any of your biological parents, brothers or sisters been diagnosed or died with any of the following before the age of 60?* Heart Attack, Angina or Stroke Cancer (including leukaemia or lymphoma) Multiple Sclerosis Muscular Dystrophy, Motor Neurone Disease or Huntington's Disease Cardiomyopathy Polycystic Kidney Disease Familial Colon Polyps Diabetes Alzheimer's Disease or Parkinson's Disease Haemochromatosis None of the above If yes, please provide details including when the condition was diagnosed* Details Person 1With the exception of holidays up to one month, have you haved, worked or travelled outside of the EU, America, Australia, New Zealand or Japan in the last 5 years or do you intend to?* Have lived, travelled or worked in the last 5 years Intend to live, travel or work in the next 2 years Neither Please select any that applyHow many pints of beer, lager or cider do you drink per week?*How many glasses of wine (standard 175ml per glass) do you drink per week?*How many measures of spirits (standard 35ml pub measure) do you drink per week?*How many other alcoholic drinks do you drink per week?*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 related to alcohol intake?*YesNoIf yes, please provide details*Have you used illegal or recreational drugs during the last 10 years? Including cannabis, ecstasy, cocaine, heroin, amphetamines and anabolic steroids?*YesNoWhat type of drug(s)?* Cannabis Ecstasy Cocaine Heroin Amphetamines Anabolic Steroids Other Do you, or do you intend to, take part in hazardous sports or activities of any kind such as aviation (other than as a fare paying passenger), hand gliding, motor sports, mountain climbing, diving or martial arts?*YesNoWhich activities?* Aviation Hand Gliding Motor Sports Mountain Climbing Diving Martial Arts Other Do you have any existing life plan or application with any insurance company?*YesNoWhich company?* Aviva Friends First Irish Life New Ireland Royal London Zurich Do you have any existing critical illness plan or application with any insurance company?*YesNoWhich company?* Aviva Friends First Irish Life New Ireland Royal London Zurich Details Person 2With the exception of holidays up to one month, have you haved, worked or travelled outside of the EU, America, Australia, New Zealand or Japan in the last 5 years or do you intend to?* Have lived, travelled or worked in the last 5 years Intend to live, travel or work in the next 2 years Neither Please select any that applyHow many pints of beer, lager or cider do you drink per week?*How many glasses of wine (standard 175ml per glass) do you drink per week?*How many measures of spirits (standard 35ml pub measure) do you drink per week?*How many other alcoholic drinks do you drink per week?*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 related to alcohol intake?*YesNoIf yes, please provide details*Have you used illegal or recreational drugs during the last 10 years? Including cannabis, ecstasy, cocaine, heroin, amphetamines and anabolic steroids?*YesNoWhat type of drug(s)?* Cannabis Ecstasy Cocaine Heroin Amphetamines Anabolic Steroids Other Do you, or do you intend to, take part in hazardous sports or activities of any kind such as aviation (other than as a fare paying passenger), hand gliding, motor sports, mountain climbing, diving or martial arts?*YesNoWhich activities?* Aviation Hand Gliding Motor Sports Mountain Climbing Diving Martial Arts Other Do you have any existing life plan or application with any insurance company?*YesNoWhich company?* Aviva Friends First Irish Life New Ireland Royal London Zurich Do you have any existing critical illness plan or application with any insurance company?*YesNoWhich company?* Aviva Friends First Irish Life New Ireland Royal London Zurich Person 1In the last 5 YEARS have you had any of the following?Any form of raised blood pressure or raised cholesterol, chest pain or irregular heart beat?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any numbness, pins and needles, optic neuritis, double/blurred vision, tremor, tingling, muscle weakness, loss or reduced power in limbs or persistent tiredness or fatigue*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of arthritis, gout, joint or ligament pain, back, spine or muscle pain or stiffness?*YesNoIncluding slipped discsPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of asthma, bronchitis, sarcoidosis, pneumonia or any other lung or breathing disorder?*YesNoIncluding: - Chronic Obsctructive Pulmonary Disease (COPD) - Sleep Apnoea - EmphysemaPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any disorder of the digestive system, liver, stomach, pancreas or bowel?*YesNoIncluding: - Reflux - Ulcers - Hernia - Crohn's Disease - Coeliac Disease - Barrett's OesophagusPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any Blood Disorders*YesNoIncluding: - Vitamin B12 Deficiency - Blood Clots - Haemochromatosis - AnaemiaPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any type of lump, growth, tumour, mole/freckle that has bled, changed in appearance or become painful or been removed?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any disorder of the kidney or bladder including blood or protein in urine, kidney failure or poly cystic kidney disease?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any abnormal smears which required further investigations, lletz treatment, mammograms, hysterectomy, endometriosis, ovarian cysts*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Been on prescribed medication for a period of 4 weeks or more or been under review from your doctor or medical professional?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Have you been referred to any specialist, been advised or undergone to have any medical tests or surgical procedures?*YesNoIncluding: - Endoscopy - Colonoscopy - MRI - CT - X-Ray - Biopsy - Blood TestPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Person 2In the last 5 YEARS have you had any of the following?Any form of raised blood pressure or raised cholesterol, chest pain or irregular heart beat?*YesNoWhen was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any numbness, pins and needles, optic neuritis, double/blurred vision, tremor, tingling, muscle weakness, loss or reduced power in limbs or persistent tiredness or fatigue*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of arthritis, gout, joint or ligament pain, back, spine or muscle pain or stiffness?*YesNoIncluding slipped discsPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of asthma, bronchitis, sarcoidosis, pneumonia or any other lung or breathing disorder?*YesNoIncluding: - Chronic Obsctructive Pulmonary Disease (COPD) - Sleep Apnoea - EmphysemaPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any disorder of the digestive system, liver, stomach, pancreas or bowel?*YesNoIncluding: - Reflux - Ulcers - Hernia - Crohn's Disease - Coeliac Disease - Barrett's OesophagusPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any Blood Disorders*YesNoIncluding: - Vitamin B12 Deficiency - Blood Clots - Haemochromatosis - AnaemiaPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any type of lump, growth, tumour, mole/freckle that has bled, changed in appearance or become painful or been removed?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any disorder of the kidney or bladder including blood or protein in urine, kidney failure or poly cystic kidney disease?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any abnormal smears which required further investigations, lletz treatment, mammograms, hysterectomy, endometriosis, ovarian cysts*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Been on prescribed medication for a period of 4 weeks or more or been under review from your doctor or medical professional?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Have you been referred to any specialist, been advised or undergone to have any medical tests or surgical procedures?*YesNoIncluding: - Endoscopy - Colonoscopy - MRI - CT - X-Ray - Biopsy - Blood TestPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember* Person 1Any form of Cancer or any type of brain or spinal growth or cyst?*YesNoIncluding: - Tumour - Lymphoma - Hodgkin's Disease - Leukaemia - MelanomaPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*A heart or artery condition or surgery on your heart or arteries*YesNoIncluding: - Heart Attack - Angina (including valves) or ciculatory system - Heart Abnormality - Cardiomyopathy - Cardiac Failure - Disease of the arteries or peripheral vascular disease - Heart Surgery - Heart MurmurPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*A stroke, brain haemorrhage, brain injury or surgery to your blood vessels in the brain or neck?*YesNoIncluding: - Mini Stroke or Transient Ischaemic Attack (TIA) - AneurysmPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any Multiple Sclerosis, Parkinson's Disease, Epilepsy or any other neurological disorder*YesNoIncluding: - Fits or Seizure - Alzheimer's - Dementia - Cerebral Palsy - Muscular Dystrophy - Motor Neurone Disease - Any disorder of the central nervous systemPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*A Positive test for HIV/AIDS or Hepatitis B or C or waiting the results of such tests?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of Mental Illness?*YesNoIncluding: - Depression - Anxiety - Stress - Insomnia - Chronic Fatigue - Eating Disorders - Addictions - or have you been referred to Psychiatrist or Hospital or Clinic as a result of any Mental IllnessPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of Diabetes, Raised Blood Sugar, or Sugar in the urine, Glucose Intolerance, Thyroid Problems, Goitre or Glandular Fever or any other Liver Disorder*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Have you ever had an application for Life Cover / Specified Illness or Income Protection declined / postponed or had special terms?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Person 2Any form of Cancer or any type of brain or spinal growth or cyst?*YesNoIncluding: - Tumour - Lymphoma - Hodgkin's Disease - Leukaemia - MelanomaPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*A heart or artery condition or surgery on your heart or arteries*YesNoIncluding: - Heart Attack - Angina (including valves) or ciculatory system - Heart Abnormality - Cardiomyopathy - Cardiac Failure - Disease of the arteries or peripheral vascular disease - Heart Surgery - Heart MurmurPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*A stroke, brain haemorrhage, brain injury or surgery to your blood vessels in the brain or neck?*YesNoIncluding: - Mini Stroke or Transient Ischaemic Attack (TIA) - AneurysmPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any Multiple Sclerosis, Parkinson's Disease, Epilepsy or any other neurological disorder*YesNoIncluding: - Fits or Seizure - Alzheimer's - Dementia - Cerebral Palsy - Muscular Dystrophy - Motor Neurone Disease - Any disorder of the central nervous systemPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*A Positive test for HIV/AIDS or Hepatitis B or C or waiting the results of such tests?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of Mental Illness?*YesNoIncluding: - Depression - Anxiety - Stress - Insomnia - Chronic Fatigue - Eating Disorders - Addictions - or have you been referred to Psychiatrist or Hospital or Clinic as a result of any Mental IllnessPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Any form of Diabetes, Raised Blood Sugar, or Sugar in the urine, Glucose Intolerance, Thyroid Problems, Goitre or Glandular Fever or any other Liver Disorder*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember*Have you ever had an application for Life Cover / Specified Illness or Income Protection declined / postponed or had special terms?*YesNoPlease provide details:*When was the condition first diagnosed?*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember* Person 1Name & Address of your Doctor*How long have you attended this Doctor?*Less than 12 monthsMore than 12 monthsHave you attended any other doctor or specialist in the last 12 months?*YesNoPerson 2Name & Address of your Doctor*How long have you attended this Doctor?*Less than 12 monthsMore than 12 monthsHave you attended any other doctor or specialist in the last 12 months?*YesNo Person 1Address* Street Address Address Line 2 Town/City County Eircode Person 2Address (2nd Person)* Street Address Address Line 2 Town/City County Eircode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country To submit this form, you need to accept our Privacy Statement* Accept Privacy StatementCommentsThis field is for validation purposes and should be left unchanged. At OneLife Insure we offer a Price Match Guarantee. We pledge to match or beat the lowest price quoted by any of the leading insurers on the market. Facebook Twitter Print Friendly
