Prior to completing this form please read each question. Please ensure that you fully understand all the questions and notes.
IMPORTANT DOCUMENTS
Section 1: Personal Details
Please use both the first name and surname in your employee records
Please provide your mobile phone number and your email address, both are needed in case we need to contact you regarding your application.
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: Partner Details (Not Applicable)
Section 2: Partner Details
Partner is defined as a spouse or civil partner or a person living in a spousal type relationship with the member for 12 months or more at the date application for cover is made.
Note: If you are including your partner, you must make them aware that you are providing Irish Life with their details. You must also inform them about the Irish Life Data Privacy Notice and where to find it.
Please complete the following details if you wish to cover your partner under the Plan.
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.
Section 3: Cover Options
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 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 confirm that I am eligible to join this plan as 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. I also confirm that I understand the key features of the Plan 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, and answered honestly and with reasonable care.
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 and where I am including my partner I have informed them about the Irish Life Data Privacy Notice and where to find it.
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.
Section 5: Salary Deduction Mandate
I instruct my employer to deduct from my salary the appropriate premium under the Specified Illness scheme and pay to Irish Life Assurance. 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 direct to Irish Life Assurance plc in accordance with the arrangements approved, the employer accepts no responsibility of any kind in that matter. Once you have been accepted for cover, premiums will be taken at the next available payroll date.
*Automatically includes the member’s Partner and Children at no additional cost
Warning: The current premium may increase after the next scheme review due on 01/01/2022.
Member Electronic Signature Agreement
Partner Electronic Signature Agreement
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.
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