"*" indicates required fields Unique ID Permanent Member Partner Accidental Death €35,000 €35,000 Loss of Limbs / Sight €35000 €35,000 Loss of Speech €35,000 €35,000 Loss of Hearing upto €35,000 upto €35,000 Other Permanent Disabilities (continental scale) up to €35,000 up to €35,000 Fracture to Arms €375 €375 Fracture to Legs €750 €750 Burns covering up to 27% or more of the body up to €3,000 up to €3,000 NOTE:This is just a summary, please refer to the explanatory booklet for more details. T&C applies. Important DocumentsMaster Policy DocumentPolicy DocumentHalligan's Terms and ConditionsThis field is hidden when viewing the formDocuments End SectionChoose your Rate* Member & Partner - €4.96 per fortnight / €10.75 per month Individual: €3.30 per fortnight / €7.15 per month Member & Partner Cover Price: Individual Cover Price: Application Date*Phone Number*Email* Our Data Protection Notice for this product is detailed overleaf. Please read this carefully. By signing this form I confirm that I have read and understood the Data Protection Notice.Member's Name*Member's DOB*Partner's NamePartner's DOBMember's Address* Street Address Address Line 2 City County Postal Code Data Protection Notice Halligan Life & Pensions Limited (the administrator) and AIG (the insurer) (“We”/“Us”), as Data Controllers, are committed to protecting and respecting your privacy in accordance with the current Data Protection Legislation. We may use the personal data held about you for the purposes of providing insurance, handling claims and any other related purposes, for offering renewal, research or statistical purposes, to safeguard against fraud and money laundering, to meet general legal or regulatory obligations and to provide you with information, products or services that you may request. You understand that we may also need to obtain and use sensitive information (such as health information) in carrying out these tasks, and without this information, a policy or claim may not be able to be processed. We may use and share your information with our group companies, affinity partners, brokers, agents, third party administrators, service providers, reinsurers, credit agencies, fraud detection agencies, loss adjusters, accountants, regulatory authorities, and as may be required by law. Your data may be transferred to destinations outside the European Economic Area (“EEA”), and where this occurs it will be treated securely and in accordance with the Legislation. Details of other insurers and third parties are available on request. You have the right to ask us not to process your data for marketing purposes, to see a copy of the personal information held about you, to have your data deleted (subject to certain exemptions), to have any inaccurate or misleading data corrected or deleted, to restrict processing, to ask us to provide a copy of your data to any controller and to lodge a complaint with the local data protection authority. Your data will not be retained for longer than is necessary and will be managed in accordance with data retention policies unless we are required to retain the data for a longer period due to business, legal or regulatory requirements. Member's Signature*Member Electronic Signature AgreementElectronic Signature Agreement* I understand and agree that my electronic signature is legally binding.*Halligan Life & Pensions Ltd t/a Halligan Insurances is regulated by the Central Bank of Ireland.This field is hidden when viewing the formAddressLineThis field is hidden when viewing the formSubmitted DateThis field is hidden when viewing the formUserIPThis field is hidden when viewing the formEntry Hash ValueThis field is hidden when viewing the formDigitalTagThis field is hidden when viewing the formCompleted Application FormThis field is hidden when viewing the formChecksumMarketing Consent Please tick this box to allow us to contact you about discounts, special offers and information by post, email, SMS, phone and other electronic means.NameThis field is for validation purposes and should be left unchanged.