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1Policy Details

2Cover Details

3About you

4About your lifestyle

5Medical

6Medical

7Doctor Details

8Confirmation

Hidden
Reference
Policy*
Single or Joint*
- Single
- Joint
Email*
Phone Number*
1st Person
Name*
First Last
Date of Birth*
Gender*
- Male
- Female
Smoker?*
- Smoker
- Non-Smoker
How much Life Cover do you require?*
How much Specified Illness Cover do you require?*
How much Mortgage Protection Cover do you require?*
2nd Person
Name (2nd Person)*
First Last
Date of Birth (2nd Person)*
DD slash MM slash YYYY
Gender (2nd Person)*
- Male
- Female
Smoker? (2nd Person)*
- Smoker
- Non-Smoker
How 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)*
Hidden
Term
How long do you need your policy to last (in years)?*
CONFIRM DETAILS & PROCEED?
- GET A QUOTE

Save and Continue Later

Choose from the available cover options*
Hidden
Your results from OneLife Insure*

Save and Continue Later

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 1
What is your marital status?*
- Single
- Married
- Cohabiting
- Separated
- Divorced
- Widowed
What is your country of birth?*
Country
Would you prefer to give your height in feet and inches or in centimetres?*
- Feet and Inches
- Centimetres
What is your height?*
What is your height?*
Would you prefer to give your weight in pounds or kilograms?*
- Stone and Pounds
- Kilograms
What 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 months
- I have used nicotine replacement products including e-cigarettes in the last 12 months
- I have NOT smoked or used nicotine replacement products including e-cigarettes in the last 12 months
- I have never smoked
What is your main occupation*
What is your employment status?
- Employee
- Self Employed
- Homemaker
- Student
- Retired
- Unemployed
Have 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 2
What is your marital status?*
- Single
- Married
- Cohabiting
- Separated
- Divorced
- Widowed
What is your country of birth?*
Country
Would you prefer to give your height in feet and inches or in centimetres?*
- Feet and Inches
- Centimetres
What is your height?*
What is your height?*
Would you prefer to give your weight in pounds or kilograms?*
- Stone and Pounds
- Kilograms
What 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 months
- I have used nicotine replacement products including e-cigarettes in the last 12 months
- I have NOT smoked or used nicotine replacement products including e-cigarettes in the last 12 months
- I have never smoked
What is your main occupation*
What is your employment status?
- Employee
- Self Employed
- Homemaker
- Student
- Retired
- Unemployed
Have 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*

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Details Person 1
With 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 apply
How 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?*
- Yes
- No
If 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?*
- Yes
- No
What 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?*
- Yes
- No
Which 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?*
- Yes
- No
Which 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?*
- Yes
- No
Which company?*
- Aviva
- Friends First
- Irish Life
- New Ireland
- Royal London
- Zurich
Details Person 2
With 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 apply
How 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?*
- Yes
- No
If 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?*
- Yes
- No
What 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?*
- Yes
- No
Which 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?*
- Yes
- No
Which 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?*
- Yes
- No
Which company?*
- Aviva
- Friends First
- Irish Life
- New Ireland
- Royal London
- Zurich

Save and Continue Later

Person 1
In 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?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
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*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any form of arthritis, gout, joint or ligament pain, back, spine or muscle pain or stiffness?*
- Yes
- No
Including slipped discs
Please provide details:*
When was the condition first diagnosed?*
*
Any form of asthma, bronchitis, sarcoidosis, pneumonia or any other lung or breathing disorder?*
- Yes
- No
Including: - Chronic Obsctructive Pulmonary Disease (COPD) - Sleep Apnoea - Emphysema
Please provide details:*
When was the condition first diagnosed?*
*
Any disorder of the digestive system, liver, stomach, pancreas or bowel?*
- Yes
- No
Including:
- Reflux
- Ulcers
- Hernia
- Crohn's Disease
- Coeliac Disease
- Barrett's Oesophagus
Please provide details:*
When was the condition first diagnosed?*
*
Any Blood Disorders*
- Yes
- No
Including:
- Vitamin B12 Deficiency
- Blood Clots
- Haemochromatosis
- Anaemia
Please provide details:*
When was the condition first diagnosed?*
*
Any type of lump, growth, tumour, mole/freckle that has bled, changed in appearance or become painful or been removed?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any disorder of the kidney or bladder including blood or protein in urine, kidney failure or poly cystic kidney disease?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any abnormal smears which required further investigations, lletz treatment, mammograms, hysterectomy, endometriosis, ovarian cysts*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Been on prescribed medication for a period of 4 weeks or more or been under review from your doctor or medical professional?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Have you been referred to any specialist, been advised or undergone to have any medical tests or surgical procedures?*
- Yes
- No
Including:
- Endoscopy
- Colonoscopy
- MRI
- CT
- X-Ray
- Biopsy
- Blood Test
Please provide details:*
When was the condition first diagnosed?*
*
Person 2
In 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?*
- Yes
- No
When was the condition first diagnosed?*
*
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*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any form of arthritis, gout, joint or ligament pain, back, spine or muscle pain or stiffness?*
- Yes
- No
Including slipped discs
Please provide details:*
When was the condition first diagnosed?*
*
Any form of asthma, bronchitis, sarcoidosis, pneumonia or any other lung or breathing disorder?*
- Yes
- No
Including: - Chronic Obsctructive Pulmonary Disease (COPD) - Sleep Apnoea - Emphysema
Please provide details:*
When was the condition first diagnosed?*
*
Any disorder of the digestive system, liver, stomach, pancreas or bowel?*
- Yes
- No
Including:
- Reflux
- Ulcers
- Hernia
- Crohn's Disease
- Coeliac Disease
- Barrett's Oesophagus
Please provide details:*
When was the condition first diagnosed?*
*
Any Blood Disorders*
- Yes
- No
Including:
- Vitamin B12 Deficiency
- Blood Clots
- Haemochromatosis
- Anaemia
Please provide details:*
When was the condition first diagnosed?*
*
Any type of lump, growth, tumour, mole/freckle that has bled, changed in appearance or become painful or been removed?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any disorder of the kidney or bladder including blood or protein in urine, kidney failure or poly cystic kidney disease?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any abnormal smears which required further investigations, lletz treatment, mammograms, hysterectomy, endometriosis, ovarian cysts*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Been on prescribed medication for a period of 4 weeks or more or been under review from your doctor or medical professional?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Have you been referred to any specialist, been advised or undergone to have any medical tests or surgical procedures?*
- Yes
- No
Including:
- Endoscopy
- Colonoscopy
- MRI
- CT
- X-Ray
- Biopsy
- Blood Test
Please provide details:*
When was the condition first diagnosed?*
*

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Person 1
Any form of Cancer or any type of brain or spinal growth or cyst?*
- Yes
- No
Including:
- Tumour
- Lymphoma
- Hodgkin's Disease
- Leukaemia
- Melanoma
Please provide details:*
When was the condition first diagnosed?*
*
A heart or artery condition or surgery on your heart or arteries*
- Yes
- No
Including:
- Heart Attack
- Angina (including valves) or ciculatory system
- Heart Abnormality
- Cardiomyopathy
- Cardiac Failure
- Disease of the arteries or peripheral vascular disease
- Heart Surgery
- Heart Murmur
Please provide details:*
When was the condition first diagnosed?*
*
A stroke, brain haemorrhage, brain injury or surgery to your blood vessels in the brain or neck?*
- Yes
- No
Including:
- Mini Stroke or Transient Ischaemic Attack (TIA)
- Aneurysm
Please provide details:*
When was the condition first diagnosed?*
*
Any Multiple Sclerosis, Parkinson's Disease, Epilepsy or any other neurological disorder*
- Yes
- No
Including:
- Fits or Seizure
- Alzheimer's
- Dementia
- Cerebral Palsy
- Muscular Dystrophy
- Motor Neurone Disease
- Any disorder of the central nervous system
Please provide details:*
When was the condition first diagnosed?*
*
A Positive test for HIV/AIDS or Hepatitis B or C or waiting the results of such tests?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any form of Mental Illness?*
- Yes
- No
Including:
- 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 Illness
Please provide details:*
When was the condition first diagnosed?*
*
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*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Have you ever had an application for Life Cover / Specified Illness or Income Protection declined / postponed or had special terms?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Person 2
Any form of Cancer or any type of brain or spinal growth or cyst?*
- Yes
- No
Including:
- Tumour
- Lymphoma
- Hodgkin's Disease
- Leukaemia
- Melanoma
Please provide details:*
When was the condition first diagnosed?*
*
A heart or artery condition or surgery on your heart or arteries*
- Yes
- No
Including:
- Heart Attack
- Angina (including valves) or ciculatory system
- Heart Abnormality
- Cardiomyopathy
- Cardiac Failure
- Disease of the arteries or peripheral vascular disease
- Heart Surgery
- Heart Murmur
Please provide details:*
When was the condition first diagnosed?*
*
A stroke, brain haemorrhage, brain injury or surgery to your blood vessels in the brain or neck?*
- Yes
- No
Including:
- Mini Stroke or Transient Ischaemic Attack (TIA)
- Aneurysm
Please provide details:*
When was the condition first diagnosed?*
*
Any Multiple Sclerosis, Parkinson's Disease, Epilepsy or any other neurological disorder*
- Yes
- No
Including:
- Fits or Seizure
- Alzheimer's
- Dementia
- Cerebral Palsy
- Muscular Dystrophy
- Motor Neurone Disease
- Any disorder of the central nervous system
Please provide details:*
When was the condition first diagnosed?*
*
A Positive test for HIV/AIDS or Hepatitis B or C or waiting the results of such tests?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Any form of Mental Illness?*
- Yes
- No
Including:
- 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 Illness
Please provide details:*
When was the condition first diagnosed?*
*
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*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*
Have you ever had an application for Life Cover / Specified Illness or Income Protection declined / postponed or had special terms?*
- Yes
- No
Please provide details:*
When was the condition first diagnosed?*
*

Save and Continue Later

Person 1
Name & Address of your Doctor*
How long have you attended this Doctor?*
- Less than 12 months
- More than 12 months
Have you attended any other doctor or specialist in the last 12 months?*
- Yes
- No
Person 2
Name & Address of your Doctor*
How long have you attended this Doctor?*
- Less than 12 months
- More than 12 months
Have you attended any other doctor or specialist in the last 12 months?*
- Yes
- No

Save and Continue Later

Person 1
Address*
Street Address Address Line 2 Town/City County Eircode
Person 2
Address (2nd Person)*
Street Address Address Line 2 Town/City County Eircode Country
To submit this form, you need to accept our Privacy Statement*
- Accept
Privacy Statement
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later

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