Dollar Life Plan Application

COMPLETE THE FORM BELOW AND SUBMIT.
WE WILL THEN ENGAGE WITH YOU DIGITALLY VIA THE EMAIL YOU SUPPLIED IN YOUR APPLICATION.

Life Assured Details

Digital Dollar Account:
Field is mandatory
You must already have a Digital Dollars account in order to apply for insurance.

Has a previous application for life insurance by yourself ever been rejected or accepted with special conditions?

The Insurer reserves the right to confirm the status of previous applications by yourself with other Insurers.

Term Life Cover Required

Term Life Cover Required
(Start at $500 up to $250,000):

Underwriting Requirements

General

How tall are you?

100.00 cm
Field is mandatory

How much do you weigh?

50.00 kg

Have you smoked any form of cigarette, e-cigarette or tobacco in the last 12 months?

Have you ever used recreational drugs, such as cocaine, heroin, ecstasy, cannabis (marijuana), amphetamines or crystal methamphetamine?

Do you travel outside the borders of the Resident Country you have elected in this application for more than 60 days per annum?

Medical Underwriting
Your Doctor’s Contact Details
Regular Doctor:
Field is mandatory
Country of Residence:
Field is mandatory
Contact No:
This field must contain Alpha Numeric characters

The Insurer reserves the right to contact your Doctor directly in order to confirm any medically related responses contained in your application.

Medical Questions

Do you currently have, or have you ever had/or received treatment for any of the following:

Heart disease/heart attack, stroke, diabetes, cancer, tumours, kidney disease and/or HIV/AIDS?

High blood pressure, high cholesterol, any form of depression and/or asthma?

Any serious head injury, fits/epilepsy or seizures?

Are you currently disabled and require the use of a wheelchair or mobility aid to move around?

Have you recently had/or are awaiting results of any medical tests/investigations or experiencing symptoms that require you to seek medical advice or treatment in the next 6 months?

Have you been prescribed or taken chronic medication or been admitted to a hospital/clinic or had surgery during the last 2 years? ((excluding tonsilitis, cesarean, flu,ingrown toe nail, hysterectomy)

Nominated Beneficiary(ies)

Name:
Field is mandatory
Surname:
Field is mandatory
ID/Passport:
Field is mandatory
Relationship:
Field is mandatory
Percentage:
0.00%
0.00%
0.00%
0.00%

At least one Beneficiary has to be nominated at this stage and you can add up to 4 beneficiaries at any time.

Premium Deduction

When would you like us to deduct your premium?
Field is mandatory

Declaration

I declare that I understand the information provided and that this is correct.


After you click on the SUBMIT, you will receive an email confirming that we have received your application and are urgently processing this.

Oops! Some went wrong... Your submission did not go through :-(×

Copyright 2014-2019. Zing Holdings Limited. All rights reserved.
Zing Life Assurance PCC is a registered Seychelles Insurer (no: 210290) - “ZingLife”.