GoldenLife. Application

Please get a Quote first. Your final quote details will be entered into this application form when you click on Apply Now.

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.

GoldenLife
Freepost 207963
P O Box 34778
Birkenhead
Auckland 0746

You can also request a hard copy brochure and application for completion offline.

FIRST LIFE TO BE INSURED
Title
Surname
First name
Middle name(s)
Address


Sex
Smoker
Age
Date of Birth	(dd/mm/yy)
Telephone	Home:
	Work:
	Mobile:

SECOND LIFE TO BE INSURED
Title
Surname
First name
Middle name(s)
Address


Sex
Smoker
Age
Date of Birth	(dd/mm/yy)
Telephone	Home:
	Work:
	Mobile:

CONTACT POLICY OWNER (If different from above)
Title
Surname
First name
Middle name(s)
Relationship to lives insured
Sex
Date of Birth	(dd/mm/yy)
Telephone	Home:
	Work:
	Mobile:

OTHER POLICY OWNER (Optional)
Title
Surname
First name
Middle name(s)
Relationship to lives insured
Sex
Date of Birth	(dd/mm/yy)

MAILING ADDRESS of CONTACT POLICY OWNER or FIRST LIFE TO BE INSURED
Address


	Note: If no policy owners are shown, the plan will be owned by the first life to be insured or if there are two lives to be insured, the plan will be owned by those two people jointly.
Do you wish to be sent mail by:	Post Email Both
Email

SUM INSURED
First life to be insured	Sum: $
First life to be insured	Premium: $
Second life to be insured	Sum: $
Second life to be insured	Premium: $

Total Premiums:	$

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"

	an application suitable for printing will be produced for your signature and mailing (or, if submitted also, to retain as a personal record)
	the application will be sent electronically and mailed to you for checking and signature

What happens next?

Your completed and signed application form will be checked and passed to FidelityLife for their underwriting.

Completion and issue is automatic and confirmed policy documents should be mailed immediately after receipt and clearance of payment. You may contact us at any stage to determine progress.

On acceptance, policy documents and a schedule will be mailed to you. We suggest you keep this in a safe place and quote the policy number whenever you wish to contact us or FidelityLife.