Free Life Cover for New Parents - Application

First name(s)

Surname

Date of birth

Number of children to be registered

Title

First name(s)

Surname

Date of birth

Are you a UK resident?

Relationship to child

Gender

I confirm that I have not received a positive diagnosis of HIV infection or have not, within the last 12 months, received medical treatment for cancer (including leukaemia and lymphoma). I understand that failure to answer this question correctly may result in a claim not being paid.

Email address

Confirm email address

Contact number

House name or numberumber

Street

Town

County

Please read the Data Protection Statement Open in new window and then tick the box to confirm that you have read and accepted it.

Please read the Important Plan Information. Opens in new window and then tick the box to confirm that you have read and accepted it.

Please read the Key Facts About Our Service. Opens in new window and then tick the box to confirm that you have read and accepted it.

We may verify your identity with a third party verification company and in certain circumstances you may be required to provide further evidence of your identity and confirmation of address, in which case Aviva will contact you.