CWU Member Life Application | Halligan Insurances

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Apply online for CWU Member Life Cover

(Children are insured from birth to age 24 in either scheme* at no additional cost)
*maximum payment of €10,000 in respect of Life Cover Benefit for Children.

Prior to completing this form please ensure that you fully understand all the questions and notes.

Before you give us your personal information it is important that you know what your data protection rights are and how and why we use your personal information. This is set out in the Irish Life Data Privacy Notice which is always available on the website at irishlifecorporatebusiness.ie or you can ask for a copy.

Section 1: Eligibility

Please read the criteria below to ensure that you are eligible to apply for cover under this Plan.
To be eligible to apply for membership of this plan Life Assurance Plan with this form you must be:
> Under age 60
> An Active in Benefit member of the CWU (ie a member working for an Employer of the plan)
> Actively at work today. This means you are:

- Working your normal contracted number of hours
- Have not received medical advice to refrain from work
- Are medically capable of fully performing the normal duties associated with your occupation
- Those on paid or unpaid maternity leave are considered ‘actively at work’
- Those on career break or other forms of unpaid leave are not considered ‘actively at work’

> Are not currently absent from work due to experiencing COVID-19 symptoms i.e. continuous cough, a high temperature or breathing difficulties, testing positive for COVID-19, being advised to have a COVID-19 test or waiting on a COVID-19 test result.

Membership of the Plan is voluntary.

Member Eligibility Agreement*

I agree (Member)*

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Section 2: Member Details

Title*

Mrs

Miss

Other

Other*

First Name*

Surname*

Please use both the first name and surname in your employee records

Marital Status*

Gender*

Male

Female

Date of Birth*

YYYY

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Member Age

Occupation*

Staff Number*

Applicants must be over 18 and under 60 years old

Full Address*

In this format - line 1, line 2, town, county, eircode

Email Address*

Mobile Number*

Home Number

Doctor Details

Depending on the information you give us in your answers to the Medical questions below, Irish Life may ask for further medical information from you and/or you GP or may ask you to have a tele-interview with a nurse. We will explain the tele-interview process in more detail in Section 9.

a) Please give the name and address of your General Practitioner (GP)

Name of GP*

Address of GP*

b) If you have changed doctor in the last 2 years, please give the name and address of that GP

Previous GP Name

Previous GP Address

Member Preferred Contact Time*

c) If Irish Life asks you to have a tele-interview, what time of day would you prefer to be contacted?

Morning

Afternoon

Evening

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Section 3: CWU Member Employment & Cover

Employer*

An Post

Eir

Vodafone

Other

Other Employer*

Frequency of Pay*

Weekly

Fortnightly

Monthly

Please choose your payment preference.*

by Salary Deduction

by Direct Debit

Please choose your payment preference.*

by Direct Debit

CWU Branch*

Office Address*

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CWU LIFE COVER BENEFITS

CWU Life Cover Plan – Table 1

AGE	CWU AVC LIFE ASSURANCE PLAN MEMBER (EMPLOYED)	SPOUSE/CIVIL PARTNER
18-34	€100,000	€100,000
35-44	€100,000	€100,000
45-54	€85,000	€75,000
55-64	€75,000	€65,000
Children are insured from Birth to age 24 for €10,000*

*Claim Benefit paid based on your age at the time of the claim.

Member Life Cover Selected

Member Life Premium

Price:

(Your premium increases to the normal rate at age 35)

Please refer to the explanatory booklet. Your cover is related to your age at date of claim.

Warning: The current premium may increase after the next review of the scheme.

Section 4: Medical and Other Information

Please read the question below and ensure that you fully understand each question before answering it.

Your personal health information

In addition to our Privacy Notice, the following is more detail relating to your personal health information that we collect and use in connection with this application. We need your relevant personal information and personal health information for underwriting decisions. This will determine whether we can offer cover and on what terms. We also need your relevant personal health information to assess and pay claims. If relevant, we will share your personal health information with reinsurers for underwriting and claims decisions. We will use your personal information for any subsequent applications to Irish Life. In addition to the personal health information we collect from you, we will request and receive your relevant personal health information from health professionals, and share your relevant personal health information with health professionals, if needed.

Relevant Information

When deciding whether to insure you and when setting the terms and conditions, Irish Life will rely on the information you have given. You must answer all questions that Irish life have asked in this form honestly and with reasonable care. Where Irish Life asks you to answer a specifc question, the subject matter of the question is relevant to the risk Irish Life is being asked to accept. If your answers are not true and complete, Irish Life may be entitled to:

- Cancel your membership and benefts under the Scheme without a return of premium.
- Refuse a claim.
- Reduce the amount of any claim.
- Reduce the amount of cover and/or.
- Treat the policy as if it had been entered into on different terms.

Relevant information includes anything that would likely influence the assessment and acceptance of an application for insurance. If you are not sure whether something is relevant relating to any of the questions asked in this section, you should disclose this information in the box provided in this section. Irish Life may also contact you to ask you for further information on your answers or as part of any subsequent claim. Irish Life may rely on the information you provide and we may not automatically clarify or confrm any information you provide. If your application for cover is accepted, Irish Life will issue you an acceptance letter. In this letter, Irish Life will ask you to advise if there has been any change to your health, circumstances, or answers to any of the questions provided in your application form. If there has been any changes between the date of your application and the date that you are accepted into the Scheme, this may affect the original acceptance terms issued to you.

Genetic Test Information

You should not tell us about any genetic test (that is, any analysis of chromosomes, DNA or RNA to detect genetic abnormalities in individuals) which you may have had. You must however, tell us if you are having treatment for, or experiencing symptoms of, a genetic condition. You will be asked for full information about your family history, including all genetic conditions.

Member Acknowledgment*

I understand (Member)*

Section 5: Preferential Entry

Preferential Entry means that once you tick Yes to confirm all of the statements in this Section, your application will be accepted based on this declaration. If you answer No or if you have any doubt and/or question regarding your ability to complete the preferential declaration, then you will be required to answer medical questions on the next page.

Please tick to confirm:

I am under age 35*

Yes

In the past 12 months...*

In the past 12 months, I have NOT been referred to or attended a consultant, specialist, hospital or clinic

Yes

I am NOT currently...*

I am NOT currently awaiting any medical appointment test or surgery or the results of any tests or surgery

Yes

In the last five years, I have NOT, because of a medical condition ...

... been refused or postponed insurance cover*

Yes

... had insurance cover offered only if I paid an extra premium*

Yes

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Medical Questions

You must answer each of the medical questions below. Your application will be medically underwritten and further medical evidence may be sought before a decision will be made on your application.

If you answer ‘Yes’ to any of the questions below please provide as much information as possible i.e. diagnosis, treatment, investigations carried out and results, what you have been told regarding your condition.

In the last year have you:

1. Been prescribed...*

1. Been prescribed, advised to take or take any medication or treatment lasting more than two weeks including tablets, creams, inhalers, drops or sprays? (you can ignore any oral contraceptive treatment)

Yes

Please fill details below

1. Date*

1. Illness*

1. Doctor*

1. Treatment*

In the last 5 years have you:

2. Had any mental health condition...*

2. Had any mental health condition requiring inpatient treatment or referral to a specialist or psychiatrist, including any eating disorder or an alcohol problem?

Yes

Please fill details below

2. Date*

2. Illness*

2. Doctor*

2. Treatment*

3. Had any medical tests, investigations or surgery?*

Yes

Please fill details below

3. Date*

3. Illness*

3. Doctor*

3. Treatment*

4. Because of a medical condition...*

4. Because of a medical condition: been refused or postponed insurance cover, had insurance cover offered only if you paid an extra premium, or had insurance over offered with one or more medical conditions excluded?

Yes

Please fill details below

4. Date*

4. Illness*

4. Doctor*

4. Treatment*

In the last 10 years have you:

5. Had diabetes, a stroke...*

5. Had diabetes, a stroke, or any problems with your heart or kidneys?

Yes

Please fill details below

5. Date*

5. Illness*

5. Doctor*

5. Treatment*

6. Had any form of cancer or a tumour or leukaemia?*

Yes

Please fill details below

6. Date*

6. Illness*

6. Doctor*

6. Treatment*

Are you currently:

7. Awaiting any appointment...*

7. Awaiting any appointment, test, surgery or investigation with your own doctor or any other medical professional?

Yes

Please fill details below

7. Date*

7. Illness*

7. Doctor*

7. Treatment*

8. Experiencing any symptoms...*

8. Experiencing any symptoms for which you have not yet sought medical advice or treatment?

Yes

Please fill details below

8. Date*

8. Illness*

8. Doctor*

8. Treatment*

Section 7: Salary Deduction Mandate

The Trustees of the CWU AVC Life Assurance Plan have appointed Halligan Insurances to collect the appropriate premiums from plan members on the Trustees behalf and to submit these to the underwriter of the Plan. The underwriter of the plan, as of 1 September 2019 is Irish Life Assurance plc. The Trustees will notify members of any change of underwriter that may occur in the future. It is each employer's responsibility to apply tax relief at source where applicable. Please read the Halligan Insurances Privacy notice here https://halligan.ie/privacy-statement/

Employer's Name*

Office section In

Staff Number*

Please deduct from my salary the appropriate contribution under the selected plan(s).
I recognise that these deductions, being made solely as a measure of convenience to me, may be terminated at any time.
I also recognise that the ultimate responsibility for ensuring that the deductions have, in fact, been made from my salary rests with myself, and that, beyond making remittances in accordance with the arrangements approved, the employer accepts no responsibility of any kind in that matter.

Member SD Agreement*

I agree (Member)*

CWU Life Assurance Plan Declaration

For Scheme No.26206 and Scheme No.26208

Warning: The current premium may increase after the next review of the CWU Life Plan scheme at 01/09/2022.

Warning - Please read the declaration below carefully and ensure that you fully understand it before signing it. If you cannot complete this declaration, please contact your financial advisor for further information.

Any words in the singular also mean the plural as applicable (e.g. ‘I’ means ‘we’ and ‘my’ means ‘our’ etc.)

Life Declaration

You must tick each statement to confirm you have read and understand the Declaration.

declaration_q1*

I understand that this application form along with supplementary information given to Irish Life will form my application for cover.

I confirm the above statement.*

declaration_q2*

I understand and agree that the information that I have provided in this application form, along with any supplementary questions answered, any statements made to Irish Life in writing or by telephone (which will be recorded in writing) and/or any information provided to Irish Life on my behalf from a GP, hospital, consultant or heath professional is material to the decision of Irish Life to allow my membership to the scheme and is relied on by Irish Life for setting my acceptance terms for membership into this scheme.

I confirm the above statement.*

declaration_q3*

I also understand that my membership into this scheme with Irish Life comprises of my acceptance terms and the following scheme documents:

> The Scheme policy document.
> The terms and conditions included in the Scheme Summary Booklet and.
> Any Scheme Review Booklets following a review.

I confirm the above statement.*

declaration_q4*

I also understand as this is a reviewable scheme the terms and conditions for the scheme may change at the subsequent rate reviews.

I confirm the above statement.*

declaration_q5*

I have read and understood the Medical and other important information section about my obligation to answer all questions asked by Irish Life in this application form and in connection with the application. I also understand that if I do not answer these questions honestly and with reasonable care, Irish Life may be entitled to:

> Cancel my membership without return of premium.
> Refuse my claim.
> Reduce the amount of any claims and or.
> Reduce the amount of cover.
> Treat my insurance as if it was entered into on different terms.

I confirm the above statement.*

declaration_q6*

I also understand that I may encounter difficulty in obtaining cover elsewhere.

I confirm the above statement.*

declaration_q7*

I have read over the answers to all the questions on this form and declare that all answers (including any answers written down for me) are true and complete. I declare that I have answered all of the questions in this form honestly and with reasonable care.

I confirm the above statement.*

declaration_q8*

I understand that if my application for cover is accepted, Irish Life will issue me an acceptance letter. In this letter, Irish Life will ask me to advise if there has been any change to my health, circumstances, or answers to any of the questions provided in my application form. If there has been any changes between the date of my application and the date I am accepted into the Scheme, this may affect the original acceptance terms issued to me.

I confirm the above statement.*

declaration_q9*

I understand that membership into this scheme will not start until Irish Life has accepted me for cover and I have paid the frst payment. I understand that Irish Life may use my personal information when underwriting any subsequent applications for cover with Irish Life.

I confirm the above statement.*

declaration_q10*

I authorise Irish Life to request and receive my personal health information now (or as part of any claim assessment including after my death) from any GPs, consultants, hospitals or other health professionals who at any time has attended me concerning my physical or mental health and to share my personal health information with any health professional for the purpose of processing my application and assessing claims.

I confirm the above statement.*

declaration_q11*

I confrm that I have completed and understand the Scheme eligibility criteria. I confrm that all answers provided by me in this regard are answered honestly and with reasonable care and I understand that my cover is dependent upon continuing to satisfy the eligibility conditions of the Scheme. I also confrm that I am actively at work today and that I understand the meaning of actively at work today* as defined below.

I confirm the above statement.*

*Actively at work today. This means you are:
- Working your normal contracted number of hours
- Have not received medical advice to refrain from work
- Are mentally and physically capable of fully performing the normal duties associated with your occupation
- Those on paid or unpaid maternity leave are considered 'actively at work'
- Those on a career break or other forms of unpaid leave are not considered 'actively at work'
- Under the age 60

I understand that where...*

I understand that where there is the potential for a period of free scheme membership at the beginning of this contract as described at the start of this application form where relevant, and I am eligible to avail of the period of free scheme membership, my full premium payments to the scheme will automatically commence at the end of the period of free scheme membership. I understand that the period of free scheme membership will commence when I am formally accepted into the scheme by Irish Life.

I confirm the above statement.*

I understand that it is a condition...*

I understand that it is a condition of membership that I accept that the Scheme is a reviewable group scheme and that at the next review date the terms of the Scheme may be amended or terminated altogether. I also understand the Scheme owner’s decisions in such matters, as agreed with Irish Life are binding on all members of the Scheme.

I confirm the above statement.*

I confirm I have been informed...*

I confirm I have been informed about Irish Life’s Data Privacy Notice and where to find this.

I confirm the above statement.*

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Member's Life Signature View

Member Life Declaration Signature*

Member Electronic Signature Agreement*

I understand and agree that my electronic signature is legally binding.*

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Member Declaration*

I agree (Member)*

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Section 8: Optional Consent

I agree to Irish Life Assurance plc sharing my personal information (excluding my personal health information) with other companies within the Irish Life Group, such as Irish Life Health. I understand this is to assist in developing combined customer services (for example, access to services from different Group companies on one online platform). This is an area that will continue to improve with a view to adding new customer engagement offerings. You can change your mind at any time and opt-out of any further sharing by emailing cbconsentoptout@irishlife.ie or writing to Irish Life Data Protection Team. If you opt-out we will keep a record of your instruction to opt-out.

Member Consent to Sharing with Other Companies in the Irish Life Group*

I agree

I don't agree

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Tele-interview - Your Questions Answered

Why are Tele-Interviews used? You may be contacted by telephone by a qualifed nurse working for MorganAsh Ltd (a specialist company that carries out the phone calls on Irish Life’s behalf) to obtain information on your present health, lifestyle, occupation, and the medical history of you and your family. Irish Life engages MorganAsh to carry out these interviews for them and the information gathered is only used by Irish Life and no other organisation has access to this.

Tele-interviews are used because: - They enable Irish Life to tailor medical questions to each applicant.
- They enable Irish Life to obtain a clear understanding of your health in order to risk assess your application more quickly and offer you the best possible terms in insurance.
- Many applicants fnd them more convenient than attending a medical examination.

The information you provide will be treated in the strictest confdence, and will be used only in the assessment of your application or in the event of a claim. With this in mind, the nurse will ask you to confrm your personal information, as a security check and to ensure confdentiality and that you are comfortable to undertake the interview at that particular time. After this, they will ask you relevant questions required to process your application.

Instruction It is essential that you provide all requested information regarding your medical history. This telephone call will be recorded. It will form part of your application for cover and, if accepted, will form the basis of your insurance contract with Irish Life along with any other medical information obtained by Irish life. Therefore, all the questions should be answered fully and honestly, as failure to do so could invalidate your cover and any future claims.

When will the tele-interview take place? You will be contact normally within a day or so of submitting your application form to Irish Life to arrange a suitable time for your interview. If, when you are called, it is not a convenient time, then just ask to re-arrange to a more convenient time.
If you have not been contacted within 3 working days, or have been away or out of touch you may like to phone MorganAsh on free-phone 1800 80 50 22. If you have call barring on yout phone please arrange to allow MorganAsh to phone you, or you like to call them on the above number.
When you schedule a time for your interview, you will be given an hour’s time slot and you should get a call in the frst 30 minutes of this hour. If you are not free to answer the questions when called, the nurse will be happy to arrange a more suitable time for the interview to take place.

The nurses are able to undertake interviews from:
- 9am to 9pm Monday to Thursday.
- 9am to 7pm on Fridays.
- 10am to 2pm on Saturdays.

It is important that you are in a confdent environment and able to speak freely and have the time to spare to complete the interview. The interview takes on average 30-60 minutes to complete. MorganAsh will not complete an interview if you are driving.

What do I need to prepare? If a Tele-Interview is deemed necessary by Irish Life then you application for insurance cannot be processed until the interview has taken place. To prepare for your interview, please take some time to gather the following information and have this to hand when you receive the call:
- Details of any medication you are currently taking(including name and dosage).
- Details of any past or present medical condition suffered (other than very minor ailments such as the common cold).
- Details of any tests or investigations, eg blood pressure, cholesterol tests.
- Details of any serious conditions, such as cancer, heart attack, stroke, suffered by a member of your immediate family (your mother, father, brothers or sisters).
MorganAsh will ask for your height and weight. If you do not know you weight, please try and weigh yourself prior to the interview.
- It is helpful to think about your recent medical history, for example, in the past few years, did you visit the doctor or have you missed any time off work? If so, why and what medication did you receive.

What if I do not wish to discuss my medical details over the phone? If you are not happy providing your medical details over the phone, please advise MorganAsh when they call you or contact Irish Life who will post you the relevant forms for your completion instead. You can then post these forms back to Halligan Insurances. If you have any questions in relation to this please contact Halligan Insurances on 01 879 7100.

What happens after the Tele-interview? You will be sent a transcript of the call to check and ensure that the information is complete and accurate. Although a little time consuming, it is in your best interest to undertake this task with due care. If you are aware of inaccurate or incomplete details or of any changes required to the report, you are required to amend the transcript and return it to Irish Life.

Conﬁrmation of Scheme Membership

Irish Life will assess the potential risk of insuring you and then make a decision on your application. This may involve attending for a medical examination. Your application may be:

> Accepted - If you are accepted as a member of the scheme your cover will begin from the date Irish Life accepts your application and you will be sent a formal acceptance letter confrming that you are a member of the scheme.
> Postponed - This means that due to you current medical circumstances, Irish Life cannot make a decision on your application but will review a new application form from you in a certain period of time eg 12 months. you will be sent a formal letter confrming your application has been postponed.
> Declined - This means that Irish Life is refusing your application for membership of the scheme. You will be sent a formal letter confrming your application has been declined.
If you application is postponed or declined, you can ask Irish Life to provide the reason for this decision, which may in certain circumstances be provided to you through your GP.

Completed forms should be returned to: Halligan Insurances, William Norton House, 575 North Circular Road, Dublin 1

Click Submit to send Application forms to Halligan Insurances.
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Halligan Life & Pensions Ltd t/a Halligan Insurances, Good Insurance is regulated by the Central Bank of Ireland.

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Completed Mem Life Application

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Apply online for CWU Member Life Cover

Section 1: Eligibility

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Section 2: Member Details

Doctor Details

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Section 3: CWU Member Employment & Cover

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Member Life Cover Selected

Section 4: Medical and Other Information

Section 5: Preferential Entry

Medical Questions

Section 7: Salary Deduction Mandate

CWU Life Assurance Plan Declaration

Member's Life Signature View

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Section 8: Optional Consent

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Tele-interview - Your Questions Answered

Conﬁrmation of Scheme Membership

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