Life Insurance Ireland Quote Form

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Unique ID
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Quotes* This field is required.Select All Required
Life
Mortgage
Income
Illness
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Applicant Age* This field is required.Please confirm your age from the dropdown
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70+
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Are you a smoker?* This field is required.*Please select "Yes" if you've smoked cigarettes or used nicotine replacements (inc vapes) within the last 12 months
Yes
No
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Life Insurance Amount* This field is required.Please enter the amount of Life Insurance you'd like a quote for
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Policy Term * This field is required.Please confirm the number of years you require cover for
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Applicants* This field is required.Please confirm if you're looking for single or dual cover
Just Me
Me & Someone Else
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Joint Applicant* This field is required.Please confirm their age from the dropdown
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70+
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Are they a smoker? *Please select "Yes" if they've smoked cigarettes or used nicotine replacements (inc vapes) within the last 12 months
Yes
No
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Policy Benefits Please select any benefits which you'd like to be quoted for
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Applicant Age* This field is required.Please confirm your age from the dropdown
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70+
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Are you a smoker? * This field is required.*Please select "Yes" if you've smoked cigarettes or used nicotine replacements (inc vapes) within the last 12 months
Yes
No
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Mortgage Balance * This field is required.Please confirm the amount outstanding on your mortgage (estimates will suffice for now)
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Policy Term* This field is required.Please confirm the number of years you require cover for
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30+
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Applicants* This field is required.Please confirm if you are looking for single or dual cover
Just Me
Me & Someone Else
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Joint Applicant* This field is required.Please confirm their age from the dropdown
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70+
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Are they a smoker?* This field is required.*Please select "Yes" if they've smoked cigarettes or used nicotine replacements (inc vapes) within the last 12 months
Yes
No
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Would you like Serious Illness Cover? * This field is required.*Serious Illness Cover pays out a tax free lump sum if you are diagnosed with a specific serious illness.
Yes
No
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Serious Illness Cover Required * This field is required.* The amount of cover agreed will be paid out if you are diagnosed with a specified serious illness
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Policy Term * This field is required.Please confirm the number of years you require cover for
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30+
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Is cover required to replace an existing policy?* This field is required.* If you have an existing serious illness policy please select yes
Yes
No
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Name of Previous Insurer * This field is required.Please select from one of the options below
Select
Select
Acorn Life
Aviva
Ark Life
Canada Life
Friends First
Irish Life
New Ireland
Caledonian Life
Royal London
Zurich
Other
If your insurer is not listed please select "other"
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Applicant Age* This field is required.Please confirm your age from the dropdown
18
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70
70+
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Are you a smoker? * This field is required.*Please select "Yes" if you've smoked cigarettes or used nicotine replacements (inc vapes) within the last 12 months
Yes
No
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Serious Illness Cover Required* This field is required.* The amount of cover agreed will be paid out if you are diagnosed with a specified serious illness
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Policy Term * This field is required.Please confirm the number of years you require cover for
1
2
3
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5
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14
15
16
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30
30+
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Is cover required to replace an existing policy? * This field is required.* If you have an existing serious illness policy please select yes
Yes
No
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Previous Insurer * This field is required.Please select from one of the options below
Select
Select
Acorn Life
Aviva
Ark Life
Canada Life
Friends First
Irish Life
New Ireland
Caledonian Life
Royal London
Zurich
Other
If your insurer is not listed please select "other"
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Applicants * This field is required.Please confirm if you are looking for single or dual cover
Just Me
Me & Someone Else
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Joint Applicant * This field is required.Please confirm their age from the dropdown
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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57
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60
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62
63
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65
66
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68
69
70
70+
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Are they a smoker?* This field is required.*Please select "Yes" if they've smoked cigarettes or used nicotine replacements (inc vapes) within the last 12 months
Yes
No
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Policy Benefits Please select any policy benefits which you'd like to be quoted for
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Applicant Age* This field is required.Please confirm your age from the dropdown
18
19
20
21
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68
69
70
70+
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Are you a smoker? * This field is required.*Please select "Yes" if you've smoked cigarettes or used nicotine replacements (inc vapes) within the last 12 months
Yes
No
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Employment Status* This field is required.Please select your employment type from the options below
Employed
Self Employed
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Occupation* This field is required.Please select from one of the options below
Select
Select
Other
Accountant
Actor
Actuary
Administrative Assistant
Agriculturist
Air Traffic Controller
Anaesthesiologist
Animal Trainer
Arborist
Architect
Artist
Assistant
Astronomer
Athlete
Attendant
Audiologist
Auto Industry
Author
Bank Clerk
Bank Manager
Bartender
Beautician
Biologist
Botanist
Business Owner
Cafeteria Worker
Captain
Carpenter
Cashier
Certified Nurse Midwife
Certified Nursing Assistant
Chef
Chemist
Chief Executive Officer
Chief Financial Officer
Child Care Provider
Chiropractor
Civil Engineer
Clergy
Clerk
Coach
Commissioner
Construction Worker
Consultant
Cosmetologist
Counsellor
Court Reporter
DJ
Defence Forces
Delivery Driver
Dental Hygienist
Dentist
Designer
Dietician
Director
Doctor
Driver
Ecologist
Economist
Editor
Educator
Electrician
Electrical Worker
Emergency Medical Technician
Engineer
Farmer
Financial Advisor
Financial Services
Firefighter
Fishing Industry
Florist
Garda
Geologist
Graphic Designer
Guidance Counsellor
Gynaecologist
Hairdresser
Horticulturist
Human Resources
Immunologist
Insurance Agent
Interpreter
Investor
IT Professional
IT Support
Janitor
Jeweller
Journalist
Judge
Labourer
Landscaper
Librarian
Maintenance Worker
Makeup Artist
Manager
Marketing
Massage Therapist
Mathematician
Mechanic
Medical Assistant
Meteorologist
Mortician
Musician
Nail Technician
Nanny
Nurse
Obstetrician
Occupational Therapist
Optometrist
Palaeontologist
Paralegal
Park Ranger
Pathologist
Paediatrician
Personal Assistant
Personal Trainer
Pharmacist
Pharmaceutical Industry
Photographer
Physical Therapist
Physician
Physician’s Assistant
Physicist
Pilot
Politician
Postal Worker
Priest
Principal
Producer
Professor
Programmer
Project Foreman
Proofreader
Proprietor
Psychiatric Nurse
Psychiatrist
Psychologist
Radiologist
Recruitment Industry
Real Estate Agent
Removals
Repair Worker
Reporter
Retail Worker
Salesperson
Scientist
Secretary
Self Employed
Server
Shop Assistant
Singer
Social Worker
Sociologist
Solicitor
Speech Therapist
Statistician
Stenographer
Surgeon
Surveyor
Tailor
Teacher
Technical Writer
Technician
Therapist
Tour Guide
Trainer
Translator
Travel Agent
Truck Driver
Underwriter
Veterinarian
Videographer
Virologist
Waitstaff
Web Designer
Writer
Zookeeper
Zoologist
* If you can't find your occupation, please select "Other"
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Cover Required * This field is required.* Please note that you can cover up to 75% of your gross annual salary less any social welfare entitlement
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Deferment Period * This field is required.Please confirm your deferment requirement from the below list
Select
Select
4 Weeks
8 Weeks
13 Weeks
26 Weeks
52 Weeks
* Please note that cover will payout after your selected deferment period
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Retirement Age * This field is required.Please confirm what your retirement age is below
Select
Select
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Plan Type* This field is required.Please confirm your required plan type below
Reviewable - The cover can be changed by the insurer once the policy is put in place.
Guaranteed - The agreed premium remains in force for the duration of the policy.
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Would you like Inflation Protection?* This field is required.* Inflation protection automatically increases your policy and premium to cover against inflation.
Yes
No
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How did you hear about us?* This field is required.Please select an option from the dropdown below
Select
Select
Google
Facebook
Twitter
Newspaper
Radio
TV
Referral
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Contact Information* This field is required.Please provide accurate contact information so that our advisors can provide you with your requested quotations.
First Name
Last Name
Please enter your email address
Please enter your mobile number
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Terms & Conditions* This field is required.To complete your quotation request please confirm you have read our terms & conditions and then click "SUBMIT"
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Unique ID
Should be Empty: