Life Insurance for New Parents

Step 1 of 5

How many people are to be covered with this plan?

Single Application

Joint Application

Primary Applicant
Title*
First Name*
Surname*
Gender*	Male Female
Marital Status*	Single Married Divorced/Separated
Maiden Name
ID No/Passport*
Date of Birth*
Country of Birth*
Country of Employment*
Occupation*

Address
House Number/Name*
Street*
City*
Post Code*
Country of Residence*

Contact Details
Home Telephone
Work Telephone
Mobile*
Email*

Secondary Applicant
Title*
First Name*
Surname*
Gender*	Male Female
Marital Status*	Single Married Divorced/Separated
Maiden Name
ID No/Passport*
Date of Birth*
Country of Birth*
Country of Employment*
Occupation*

Address
Copy from Primary
House Number/Name*
Street*
City*
Post Code*
Country of Residence*

Contact Details
Home Telephone
Work Telephone
Mobile*
Email*

Step 2 of 5

Details of Baby
First Name(s)*
Surname*
Gender*	Male Female
ID No/Birth Certificate No*
Date of Birth*
Country of Birth*
Upload Child's Birth Certificate

Step 3 of 5

Insurance Plan
Sum Insured
Term
Plan Type

Step 4 of 5

Primary Applicant - Medical
Have you received any form of medical treatment for cancer in the past 12 months?
No Yes
Have you been diagnosed with HIV infection?
No Yes
Do you work or reside outside of the Maltese Islands?
No Yes

Secondary Applicant - Medical
Have you received any form of medical treatment for cancer in the past 12 months?
No Yes
Have you been diagnosed with HIV infection?
No Yes
Do you work or reside outside of the Maltese Islands?
No Yes

Step 5 of 5

Disclaimer

I declare that the information given on this Application Form is true, accurate and complete and that no material fact has been withheld. I understand that failure to disclose a material fact may result in the contract being declared void and that a claim under the policy may not be paid.

A material fact is one which is likely to influence MSV Life in the best assessment and acceptance of this Application Form. If in doubt as to whether a fact is material, then it should be disclosed. I understand that the contract will not be in force until the Application Form has been accepted by MSV Life in writing.

I have received / read a copy of the ‘Information Guide’ of the product for which I am applying and understand its content. The Application Form and the Policy Document shall be the basis of the contract between myself and MSV Life.

I acknowledge and accept that MSV Life may process the personal data that I provide in this Application Form in accordance with the Data Protection Act, 2001 and with the Data Protection Policy of MSV Life (a copy of which is available from MSV Life’s offices, website and Tied Insurance Intermediaries).

I acknowledge that I have a right to request access to and rectification of such data as processed by MSV Life. Any such request must be signed by myself as the Policy Owner to whom the personal data relates.

Primary Applicant
By clicking 'I Agree', you are confirming that you have read and that you agree with the terms and conditions laid out in the disclaimer.
I Agree

Secondary Applicant
By clicking 'I Agree', you are confirming that you have read and that you agree with the terms and conditions laid out in the disclaimer.
I Agree

Step 1 of 5

Primary Applicant

Address

Contact Details

Secondary Applicant

Address

Contact Details

Step 2 of 5

Details of Baby

Step 3 of 5

Insurance Plan

Step 4 of 5

Primary Applicant - Medical

Secondary Applicant - Medical

Step 5 of 5

Primary Applicant

Secondary Applicant