Apply Now

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.

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

if you prefer assistance, 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 be used for Life and Total Permanent Disablement applications up to $1 million, Living Assurance and Progressive Care applications up to $500,000 (inclusive of all existing Sovereign cover) and Waiver of Premium.

1. Life to be Assured

Title:
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Last Name:
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First Name:
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Previous Name:
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Postal Address
Address 1:
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Address 2:
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Address 3:
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Email:
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Home phone:
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Business phone:
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Mobile phone:
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Birthday:
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Gender:
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Occupation:
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Industry:
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2. Ownership

Ownership:
Same as Life Assured
Life Assured and secondary owner (fill out details below)
Separate owner (fill out details below)
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Title:
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Last Name:
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First Name(s):
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Previous Name:
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Postal 1:
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Postal 2:
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Postal 3:
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EMail:
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Day time phone:
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Birthday:
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Gender:
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If you answer 'yes' to any of the questions below we may need to contact you for more information.

Contact Method:
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Policy number:
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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
GP/Specialist/Clinic Name
Reason for visiting
Visit reason
Address
Years/months attended
Date
Do they hold your medical records
Do they have your records?
Agree:
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3. Children to be Assured

Child 1
Last Name:
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First Name:
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Gender:
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Birthday:
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Birth place:
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Child 2
Last Name:
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First Name:
Gender:
Birthday:
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Birth place:
Child 3
Last Name:
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First Name:
Gender:
Birthday:
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Birth place:
Child 4
Last Name:
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First Name:
Gender:
Birthday:
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Birth place:

4. Benefit Details

Life:
To provide a lump sum in the event of death of the Life to be Assured.
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Amount of cover: $:
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Accident:
To provide a lump sum in the event of an accident.
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Amount of cover: $:
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Critical Illness:
To provide a lump sum in the event of a diagnosis of a specified condition of the Life to be Assured.
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Amount of cover: $:
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Policy Type:
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Tot.Perm.Disablement:
To provide a lump sum in the event of an accident.
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Amount of cover: $:
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Waiver of Premium:
To provide a lump sum in the event of an accident.
Amount of cover: $:
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5. Your Insurance Details

If 'Yes', give details below

Name of Company
Type of cover
Sum insured
Date commenced
To be replaced?
If 'Yes', give details
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If 'Yes', give details:
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6. Personal Statement

a Height/Weight
Height 
Weight 
b Smoking
Have you smoked anything during the last 12 months?
Smoking
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If yes:
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c Drugs
Do you use, or have you ever used recreational and/or non-prescription drugs (except 'over the counter' medications)?
If 'Yes', give details
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d Alcohol
How many standard alcoholic drinks do you have per week on average? (standard drink = 1 nip or 30ml spirits, 100ml wine, 300ml beer)
Alcohol:
eHave you ever received or are you considering seeking
medical advice, counselling, or treatment for the use of alcohol, drugs or gambling?
If 'Yes', give details:
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fResidency
Are you a permanent resident of New Zealand?
If 'No', give details:
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gOverseas
Do you intend to live, work or travel overseas, except for Australia or the Cook Islands in the next 12 months?
If 'Yes', give details:
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h Have you ever engaged, or are you likely to engage in any hazardous or high-risk occupation, activity, sport or pastime? (e.g. aviation, motor sports, diving, mountaineering)
If 'Yes', give details:
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iHave either of your parents or any of your brothers or sisters suffered from (before the age of 60): diabetes, stroke, heart disease, high blood pressure, kidney disease, polycystic kidney, cancer (please specify type), Huntington's chorea, multiple sclerosis, mental illness, dementia, or any other hereditary or familial disease.
If 'Yes', give details:
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j Illness
Have you ever suffered from any of the following illnesses/conditions?
1.
Stroke, epilepsy, or neurological disorder (e.g. motor neuron disease, MS, paralysis, seizures)
2.
Mental illness, nervous disorder, stress, depression, fatigue or phobia
3.
Any disease or disorder of the eyes, ears, nose or throat (including loss of sight, hearing or speech)
4.
Thyroid disorder or any other glandular condition
5.
Respiratory disorder (e.g. asthma, bronchitis, sleep apnoea, breathing problems)
6.
Chest pain, heart complaint, high blood pressure or high cholesterol
7.
Any condition of the gastrointestinal tract or bowel (e.g. irritable bowel, Crohn's disease, ulcers, colitis, reflux)
8.
Obesity (e.g. stomach stapling)
9.
Liver disease or disorder (e.g. hepatitis)
10.
Diabetes or abnormal blood sugar level
11.
Kidney, bladder, genital or urinary problem (e.g. prostate, urinary incontinence, kidney stones)
12.
An injury, disease or disorder of muscle, joint or bone (including arthritis, rheumatism, SLE, gout)
13.
Cancer, tumour, cyst, breast lump, abnormal moles, skin disorder or any other lesion
14.
Blood disorders (e.g. anaemia, varicose veins, blood clots, bleeding tendencies)
15.
AIDS or HIV antibodies
16.
Any other illness or condition not listed above
If 'Yes':
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17.
FEMALES ONLY: Any condition relating to the breast, cervix, uterus, fallopian tube, ovary or the female genital tract (e.g. abnormal smear, endometriosis, heavy/painful/irregular menstrual bleeding, fibroids)
kOther
Other than what you have disclosed above,
have you experienced any health problems within the last five years
or
Have you ever had, been referred for, or are you considering seeking any medical advice, counselling, investigations, blood tests, treatment or operations?
 
Condition
Date
of first symptoms
Date
of last symptoms
Details (include treatment, test results, time off work, recurrence, current status)
Are you receiving or have you been advised that treatment followup is required?
Have you ever had any reoccurance of this condition?
 

7. Occupation Details

(complete part 7 if applying for Total Permanent Disablement or Waiver of Premium)
aOccupation
What is your current main occupation?
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bSelf-Employment
Are you:
Employed
Self Employed (less than 3 years)
Self Employed (more than 3 years)
cDuties
Describe your main occupation duties in full:
dPlans
Are you intending to change your occupation or duties ?
If 'Yes', give details
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eHours
Number of hours worked
 hours per week
fHome Workplace
Do you work from home?
gHome Workplace Details
If 'Yes', give details of your home set up and % of time spent in this workplace:
hOther Occupation
Do you have any other occupation?
If 'Yes', give details
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iOccupation History
Give details of your current and previous occupations during the last five years
Date from
Date to
Occupation
Employer
jBankruptcy, Criminal Conviction
Have you ever been declared bankrupt and/or convicted of any criminal offence?
If 'Yes', give details
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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.
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Validation

Please help us distinguish between a real individual and spam robots by typing the 1st word in the list below:
"beautiful green chance fine nice"
 
To process your application, click one of the green buttons.
Submit Application – the NZLife application form will be sent electronically and then 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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