Unique ID

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

IMPORTANT DOCUMENTS

Plan Explanatory Booklet

Halligan's Terms of Business

Irish Life Terms of Business

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 irishlifecorporatebusiness.ie or you can ask us for a copy.

Section 1: Personal Details

Title*

Mrs

Miss

Other

Other*

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

Applicant's Name*

First Name Surname

Department

Marital Status*

Please provide your mobile phone number and your email address, both are needed in case we need to contact you regarding your application.

Mobile Number*

Work Number

Email Address*

Home Address*

Address1 Address2 City County Eircode

Hidden

Home Address*

Date of Birth*

Gender*

Male

Female

Hidden

Member Age

Do you have a Spouse/Civil Partner to include?*

Yes

Partner is deﬁned as a person living in a spousal type relationship with the member for 12 months or more at the date the application for cover is made. Whenever we mention a partner in this application form, we refer to a spouse, civil partner or partner.

Section 2: Cover Options

AGSI Cover Plan

OPTION	BENEFIT	COST
Upto age 50 years (new entrants can enrol upto age 57)	€26,000 SIC	€5.66 per week (member and partner*)
Age 50 upto 65 years	€11,900 SIC	€5.66 per week (member and partner*)
Children’s SIC Benefit aged 30 days upto 25 years	€20,000	Included
Children’s Death Benefit aged 1 upto 21 years	€10,000	Included
Hospitalisation expenses after 7 consecutive days, payable for 182 days	€35 per day	Included

Note: Children’s benefit (either Life Cover or Serious Illness Cover) is only payable once per child per policy

Member’s contribution is €5.66 per week and automatically includes the member’s Spouse and Children at no additional cost.

*Partner is deﬁned as a person living in a spousal type relationship with the member for 12 months or more at the date the application for cover is made. Whenever we mention a partner in this application form, we refer to a spouse, civil partner or partner.

Warning: The current premium may increase after the next scheme review due on 01/01/2022.

Section 3: Partner Details (Not Applicable)

Section 3: Partner Details

Please complete the following details for a partner where applicable for cover options.

Partner's Name*

First Name Surname

Partner's Date of Birth*

Hidden

Spouse Age

To be completed by those who want their partner covered: I wish to include my partner for cover under the AGSI Group Specified Illness Cover (SIC) plan. I understand that partner is defined as a person living in a spousal type relationship with the member for 12 months or more at the date application for cover is made. I understand that my partner, as stated above, is covered under the plan, unless I notify my employer of a change in circumstances.

Note: A person can become a member of the AGSI Group Specified Illness Cover (SIC) Plan either as an AGSI member or the partner of an AGSI member, but not both i.e. only one amount of Benefit will ever be paid to, or in respect of any given person under the AGSI Group SIC Plan, even if that person is both an AGSI member and also the partner of another AGSI Member.

Hidden

Table Break

Section 4: Declaration - You must read carefully before signing

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

Plan Declaration

I understand and agree that my contract with Irish Life Assurance plc (Irish Life) will be based on the declarations in this form, my completed application form (online or otherwise), any supplementary questions answered, any statements made to Irish Life in writing or by telephone, and all terms and conditions given to me by Irish Life.

I, a member of AGSI, (or a spouse/civil partner/partner of a member of AGSI) confirm that I have read and fully understand the corresponding booklet in relation to AGSI Group Specified Illness Cover plan including the sections on pre-existing conditions and the six-month cancer moratorium and accordingly, I now apply to join this plan.

I understand that where I have a medical history, previous medical conditions or symptoms described in the pre-existing conditions clause, Irish Life will not pay a claim and I may encounter difficulty in obtaining cover elsewhere. I also understand that this is a reviewable scheme and the benefits and/or costs can change at the next review date.

I declare that all information, statements and answers I have provided, are true and complete.
I understand that Irish Life can use my personal information for any subsequent applications to Irish Life.
I can confirm that I have received, read and understand the key features of the scheme booklet.
I confirm I have been informed about the Irish Life Data Privacy Notice and where to find it.

Applicant's Signature*

Hidden

Partner's View

Partner's Signature*

Hidden

Table Break

Section 5: 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

Applicant's Signature*

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

I agree

I don't agree

Partner's Signature*

Section 6: Salary Deduction Mandate

Please deduct from my salary the appropriate contribution under the Specified Illness scheme. 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.

Weekly Premium*

Price:

*Automatically includes the member’s Partner and Children at no additional cost

Employer's Name*

Employer's Address*

Staff Number*

Member's Date of Birth*

Warning: The current premium may increase after the next scheme review due on 01/01/2022.

Member Electronic Signature Agreement

Member Electronic Signature Agreement*

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

Partner Electronic Signature Agreement

Partner Electronic Signature Agreement*

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

Please ensure all details entered are correct prior to submitting!

In the interest of customer service, calls will be monitored.

Halligan Life & Pensions Ltd t/a Halligan Insurances, Good Insurance is regulated by the Central Bank of Ireland. Registered Number: 120399.

Irish Life Assurance plc is regulated by the Central Bank of Ireland. Irish Life Assurance plc, Registered in Ireland Number 152576, VAT number 9F55923G.

Click 'Submit Application' below to send.
Please don't close or click back on your browser after clicking Submit.
A confirmation page will be displayed when completed.

Hidden

Table Break

Hidden

UserIP

Hidden

Submitted Date

Hidden

Entry Hash Data

Hidden

Entry Hash Value

Hidden

DigitalTag_Member

Hidden

Completed Application Form

Hidden

Checksum

Upload Your Profile

IMPORTANT DOCUMENTS

Section 1: Personal Details

Section 2: Cover Options

Section 3: Partner Details (Not Applicable)

Section 3: Partner Details

Table Break

Section 4: Declaration - You must read carefully before signing

Partner's View

Table Break

Section 5: Optional Consent

Section 6: Salary Deduction Mandate

Member Electronic Signature Agreement

Partner Electronic Signature Agreement

Table Break

REQUEST A CALL BACK