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.

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 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

Height
Weight
Smoking
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If yes:
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If 'Yes', give details
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Alcohol:
If 'Yes', give details:
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If 'No', give details:
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If 'Yes', give details:
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If 'Yes', give details:
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If 'Yes', give details:
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(j.) 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)
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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)

(k.) Other than what you have disclosed above:

Condition
Date of first symptoms
Date of last symptoms
Details (include treatment, test results, time off work, recurrence, current status)Details
Are you receiving or have you been advised that treatment followup is required?Followup treatment required?
Have you ever had any reoccurance of this condition?Any reoccurance?

7. Occupation Details

(complete if applying for Total Permanent Disablement or Waiver of Premium)

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Employed
Self Employed (less than 3 years)
Self Employed (more than 3 years)
If 'Yes', give details
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 hours per week
If 'Yes', give details
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(i) Give details of your current and previous occupations during the last five years

Date from
Date to
Occupation
Employer
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 4th word in the list below:
"affection dream picnic cherish enjoy"

   

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)