GoldenLife.

Online Insurance for NZ
Freephone 0800 269543
artwork for Golden Life

Get a free real-time quote now · Anonymous · Valid for 30 days

Insurance Application

Please get a Cost Quote first. Your details will be carried here when you complete Step 2.

You can complete the application form below, and:

Golden Life
Freepost 207963
P O Box 34778
Birkenhead
Auckland 0746

1. FIRST LIFE TO BE INSURED

Title
Mr Mrs Miss Ms Dr Other
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Surname
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First name(s)
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Residential Address
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Postcode
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Sex
Select Male Female
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Smoker
Select No Yes
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Date of Birth
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Telephone
Home:
Work:
Mobile:
 

2. SECOND LIFE TO BE INSURED

Title
Mr Mrs Miss Ms Dr Other
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Surname
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First name(s)
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Residential Address
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Postcode
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Sex
Select Male Female
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Smoker
Select No Yes
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Date of Birth
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Telephone
Home:
Work:
Mobile:
 

3. CONTACT POLICY OWNER (If different from above)

Title
Mr Mrs Miss Ms Dr Other
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Surname
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First name(s)
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Relationship to lives insured
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Sex
Select Male Female
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Date of Birth
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Telephone
Home:
Work:
Mobile:
 

4. OTHER POLICY OWNER (Optional)

Title
Mr Mrs Miss Ms Dr Other
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Surname
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First name(s)
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Relationship to lives insured
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Sex
Select Male Female
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Date of Birth
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MAILING ADDRESS of CONTACT POLICY OWNER or FIRST LIFE TO BE INSURED
Address
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City
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Postcode
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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 documents by:
Post Email or to Both
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Email
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5. SUM INSURED / PREMIUM

First life to be insured Sum: $
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Premium per month: $
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Premium fortnightly: $
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Second life to be insured Sum: $
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Premium per month: $
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Premium fortnightly: $
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Requested Payment Plan:
Monthly Fortnightly
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Direct Contact

Contact:
EMail Telephone AM Telephone PM
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Security

Please enter the red security code:

285 4 0 9 4 5 7 5 4 1 
 

Declaration

Your Duty of Disclosure for the Life to be Insured and Policy Owner(s)

Before you enter a contract of insurance and before your contract of insurance commences you have a duty to disclose to Fidelity Life every matter that is relevant to Fidelity Life's decision whether to accept the risk of insurance and if so on what terms. If you fail to comply with your duty of disclosure, Fidelity Life may cancel your policy from inception, or at its discretion, alter the amounts and terms of the insurance or decline to consider any claim/s. If Fidelity Life cancels your policy from inception, all premiums paid may be forfeited.

  • I confirm that I have not been diagnosed with any illness or disease that is expected to cause death within 12 months.
  • I confirm that I am a citizen/permanent resident of New Zealand and living in New Zealand.
  • I acknowledge that this application collects personal information about me that I have the right to access and to correct. The information will be used by Fidelity Life, its officers, third parties for processing on Fidelity Life's behalf, its reinsurers and its advisers to calculate and administer the plan and for the purposes of promotion of insurance and investment services. This information may also be used for statistical purposes provided you are not identified. Fidelity Life holds the information securely at 81 Carlton Gore Road, Newmarket, Auckland.
  • The information may be disclosed outside of Fidelity Life group of companies where the disclosure is necessary for one or more purposes for which the personal information was collected, to the adviser named on this application (or allocated to your business), where required by law, to the policy owner and with your consent.
  • I declare that I have read the notice explaining duty of disclosure, and have completed or read this application and the information given is true, accurate and complete. I have not withheld or misstated any material fact.
  • No statement affecting this insurance has been made to any representative of Fidelity Life that is not recorded in this proposal.
  • The information I have provided and the information provided by anyone else on my behalf in this proposal will form the basis of the contract between Fidelity Life and me.
  • The contract of insurance will not commence until Fidelity Life has accepted this application.
  • I authorise Fidelity Life to obtain any information about the state of health of any life insured from any medical practitioner that I may have consulted. I shall be bound by the terms and conditions in the policy to be issued to me by Fidelity Life.
  • If I have provided my email address in this application, or if I provide it at some stage in the future, I consent to receiving email from Fidelity Life in respect of Fidelity Life and any further services.
14 Day Free Look
  • If I am not satisfied with the policy I may cancel by returning it to us within 14 days of its receipt, provided no claim is made, and receive a full refund of premium paid.

Financial Strength Rating

Paper or Electronic


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 to Costello Financial Services and then 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.