Application Form
How you would like us to refer to
Would you like this policy to
1. Life to be assured Life 1 to be assured Title: Please Select Mr Mrs Miss Ms Last Name: First Name(s): Home address: Mailing address: Email: Home phone: Business phone: Mobile phone: Date of birth: Place of birth: Gender: Please Select Male Female Previous Name: Height: Weight: Life 2 to be assured Title: Please Select Mr Mrs Miss Ms Last Name: First Name(s): Home address: Mailing address: Email: Home phone: Business phone: Mobile phone: Date of birth: Place of birth: Gender: Please Select Male Female Previous Name: Height: Weight: Children to be assured Child 1 Last Name: First Name(s): Date of birth: Place of birth: Gender: Please Select Male Female Child 2 Last Name: First Name(s): Date of birth: Place of birth: Gender: Please Select Male Female Child 3 Last Name: First Name(s): Date of birth: Place of birth: Gender: Please Select Male Female Child 4 Last Name: First Name(s): Date of birth: Place of birth: Gender: Please Select Male Female 2. Policy owner(s) Please specify policy ownership Please Select Life 1 to be assured Life 2 to be assured Both lives to be assured 3. Payment detailsPlease complete offline on printed form to ensure security Premium amount $ Deposit enclosed $ Payment frequency
Payment method
Direct Debit form and complete the Sovereign Direct Debit Authority section)
OR
OR
4. Benefit Details Plan Selected: Hospital Only - 2 Adults, including children 5. Personal Statement We understand that the medical questions we ask in this section may be sensitive, but it is important that you give us all the information that may affect
your application for insurance. If you prefer, you can complete this form in private and post it directly to Sovereign at Private Bag Sovereign, Auckland
Mail Centre 1020.
If you answer ‘YES’ to any of the following questions, please provide the details in the space provided. If more space is required please use a separate
sheet of paper and attach it to this application. Please give as much detail as possible including details of any medical condition, treatment, dates of
treatment and results, and be sure to indicate who the information relates to.
Health Information Please provide the name and address of your usual doctor and any other doctor holding your records if different. Life 1 assured Doctor's name Doctor's address Patient since Life 2 assured Doctor's name Doctor's address Patient since Child 1 Doctor's name Doctor's address Patient since Child 2 Doctor's name Doctor's address Patient since Child 3 Doctor's name Doctor's address Patient since Child 4 Doctor's name Doctor's address Patient since A) Have you had a medical exam, test, x-rays or advice, treatment or surgery from a health professional in the last five years? Please choose Yes or No.
B) Are you currently receiving treatment, tests or observation from a health professional? Please choose Yes or No.
C) Are you considering seeking advice, treatment, tests or surgery for your health? Please choose Yes or No.
D) Do you suffer, or have you ever suffered from, or have you ever had treatment or surgery or medical tests or prescribed medication for any of the following? Please choose Yes or No. Ears, eyes, nose, throat:
Oral surgery, wisdom teeth problems:
Heart complaint, chest pain, high blood pressure, high cholesterol:
Breathing problems including asthma, bronchitis, respiratory disease:
Brain or neurological disorder such as epilepsy, stroke, multiple sclerosis:
Kidney disease, kidney stones, kidney infections:
Liver disease or disorder:
E) Do you suffer, or have you ever suffered from, or have you ever had treatment or surgery or medical tests or prescribed medication for any of the following? Please choose Yes or No. Diabetes, gout, thyroid disorder:
Bladder, urinary or prostate condition:
Gastro-intestinal problems including bowel complaints, ulcers or colitis:
Cancer, tumour or cyst:
Disease, disorder or injury to bones, muscles, joints, including arthritis and rheumatism:
Reproductive organs, gynaecological disorders, abnormal cervical smears:
Breast lumps, lesions or cysts:
Varicose veins:
Blood disorder including anaemia and clotting disorders:
Irregular, heavy or painful menstrual bleeding, ovarian or hormonal problems, abortion or miscarriage:
F) Is your health impaired in any way? Please choose Yes or No.
G) Do you suffer from, or have you ever suffered from, any other illness, sickness, disease or injury or medical condition? Please choose Yes or No.
If you answered ‘Yes’ to any of the questions, please give full details, including the name of life or child to be assured, medical condition, treatment received and dates of treatment. Supplementary Information H) Does any life, or child, to be assured currently smoke? If ‘Yes’, please provide the names of those who smoke and details.
Has any life, or child, to be assured ever smoked?
I) Do all lives, or children, to be assured have Permanent Residence, New Zealand citizenship or a Work Permit or Student Permit with a duration exceeding two years?
If ‘No’ please give full details: J) If we require further information to complete this application, can we use our Telephone Underwriting Service?
Telephone underwriting is a service that helps us process your Application quickly and simply. If we require information, a Sovereign Telephone Underwriter will phone you at a time and place that is most convenient to you. They may ask you questions about your health so we can process your Application. We use this additional information to assess the acceptance terms for your Application. The information you provide will be taken down and a copy of the questions and your answers will be posted to you. We ask that you check that the details are correct and advise us of any necessary amendments, within 7 days of receiving this information. 6. Additional information Please attach any additional information you wish to supply to this document. Validation: "nice treasure love enjoy chance"
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)
