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THE CWU ADDITIONAL VOLUNTARY CONTRIBUTION LIFE ASSURANCE PLAN

Reduced Underwriting for New Members under age 45
Please complete this form if you are under age 45 and applying to join the Plan for the first time between 1 April 2026 - 30 June 2026
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 Life Assurance Plan with this form you must be:

> Under age 45

> An Active in Benefit member of the CWU (i.e. 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’

Membership of the Plan is voluntary.
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 our website at www.irishlife.ie/privacy-notice or you can ask us for a copy
Member Eligibility Agreement*
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Section 2: Member Details

Title*
Please use both the first name and surname in your employee records
Gender*
DD slash MM slash YYYY
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Applicants must be over 18 and under 60 years old
In this format - line 1, line 2, town, county

Section 3: CWU Member Employment & Cover

Employer*
Frequency of Pay*
Please choose your payment preference.*
Please choose your payment preference.*
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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

(Your premium increases to the normal rate at age 35)
Important: The maximum amount of lump sum death benefit Revenue will permit to be paid is four times salary, taking into account all similar benefits arising under retirement or death benefit insurance
Warning: The current premium may increase after the next review of the scheme at 01/06/2028.

Section 4: Medical and Other Information

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

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

> I am not currently awaiting any medical appointment, test or surgery or the results of any tests or surgery.

In the last five years, I have not because of a medical condition:

> Been refused or postponed insurance cover.

> Had insurance cover offered only if I paid an extra premium.

Member Acknowledgment*

Section 5: Scheme 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 01/06/2028.
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.
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.
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.
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.
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.
declaration_q6*
I also understand that I may encounter difficulty in obtaining cover elsewhere.
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.
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.
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.
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.
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.
*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.
declaration_q11*
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 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 I have been informed...*
I confirm I have been informed about Irish Life’s Data Privacy Notice and where to find this.

Section 6: 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/
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*
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Member's Life Signature View

Clear Signature
Member Electronic Signature Agreement*
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Member Declaration*
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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
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Marketing Consent

Irish Life Assurance plc, trading as Irish Life, is regulated by the Central Bank of Ireland.

Halligan Life & Pensions Ltd t/a Halligan Insurances is regulated by the Central Bank of Ireland.

In the interest of customer service we will monitor calls.

Irish Life Assurance plc, Registered in Ireland Number 152576, VAT number 9F55923G.

Irish Life, Lower Abbey Street, Dublin 1, Ireland. T: 01 704 2000 • F 01 704 1905

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Halligan Insurances, William Norton House, 575 North Circular Road, Dublin 1
 info@halligan.ie 
 01 879 7100
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Halligan Life & Pensions Ltd trading as Halligan Insurances is regulated by the Central Bank of Ireland. Registered Office: Otter House, Modern Plant Building, Naas Road, Dublin 22. Registered Number: 120399
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