Client Refund Request FormPolicy Type(Required)Life and/or Specified Illness and/or PensionMotor and/or HouseholdStudent Health InsuranceOtherOther(Required)Contact DetailsTitle(Required)Mr.Ms.Mrs.Miss.Name(Required) First Last Customer Reference(Required)Policy NumberEmail(Required) Contact Number(Required)Home Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code Your Bank DetailsBIC(Required)IBAN(Required)Company Details: Halligan Life & Pensions Ltd - Creditor’s ID No: IE95SDD303969 William Norton House, North Circular Road, Dublin 1. Ireland.NameThis field is for validation purposes and should be left unchanged.