Unique IDPrior to completing this form please read each question. 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 our website at http://www.irishlifecorporatebusiness.ie or you can ask us for a copy.Section 1: EligibilityIf you meet the following conditions, you are eligible to join the Plan. You are: • An Active in Benefit member of the CWU (ie 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 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 career break or other forms of unpaid leave are not considered 'actively at work' • Under age 60 Membership of the Plan is voluntarySection 2: Personal DetailsTitle*MrMrsMissMsOtherOther*First Name*Please use both the first name and surname in your employee recordsSurname*Address*Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleMarital Status*SingleMarriedCivil PartnerAgeSection 3: Employment DetailsEmployer Name*Office Address*Office Address 2Frequency of Pay*WeeklyFortnightlyMonthlySection 4: Applying for coverI wish to apply for:Member Life cover for those aged between 18-34*€2.00 per week€4.00 per fortnight€8.88 per monthMember Life cover for those aged 35+*€3.89 per week€7.78 per fortnight€16.85 per monthPlease refer to the booklet for the age related cover you get for this cost. Warning: The current premium may increase after the next review of the scheme at 01/09/2022.Section 5: Medical and Other InformationYour personal health information In addition to our Irish Life Data Privacy Notice, the following is more detail relating to your personal health information that we collect and use in connection with this plan contract. We need your relevant personal information and personal health information for underwriting decisions. This will determine whether we can offer cover and on what terms. We also need your relevant personal health information to assess and pay claims. If relevant, we will share your personal health information with reinsurers for underwriting and claims decisions. We will use your personal information for any subsequent applications to Irish Life. In addition to the personal health information we collect from you, we will request and receive your relevant personal health information from health professionals, and share your relevant personal health information with health professionals, if needed. Material Facts You must tell us all relevant information when answering all of the questions. If you do not, or if any answers are not true and complete, we could treat the plan as void. This includes disclosing tobacco consumption or use of nicotine replacement products including e-cigarettes. If you fail to reveal all material facts there will be no cover under the plan, we will not refund the payments and we will not pay a claim. A material fact (relevant information) includes anything that would likely influence the assessment and acceptance of an application for insurance. If you are not sure whether something is relevant, you should tell us anyway. If there is anything not covered by the questions on this form that you think we should know, please tell us in the section ‘Additional Information’. We may also contact you if we need to ask you for further information on your answers or as part of any subsequent claim. We will rely on what you tell us and we will not automatically clarify or confirm any information you provide. If your health, circumstances, or answers to any of the questions in this application form change between the date you apply for cover and the date your application is accepted, you must let us know immediately as failure to do this may result in a claim being refused. Genetic Test Information You should not tell us about any genetic test (that is, any analysis of chromosomes, DNA or RNA to detect genetic abnormalities in individuals) which you may have had. You must however, tell us if you are having treatment for, or experiencing symptoms of, a genetic condition. You will be asked for full information about your family history, including all genetic conditions.Section 6: GP DetailsPlease give the name and address of your General Practitioner (GP)Name of GP*Address of GP*If you have changed doctor in the last year, please give the name and address of your previous doctor.Previous GP NamePrevious GP AddressSection 7: Which Application route should I take?There are two application options:1. Preferential Entry - this means that once you tick to confirm all of the statements in Section 8, your application will be accepted based on this declaration. If you have any doubt and/or question regarding your ability to complete the preferential declaration, then you should apply using the medical questions route as described in the next paragraph.2. Medical questions - This means that , as you cannot tick to confirm all of the statements in Section 8 are true to you, you must answer each of the medical questions in Section 9. Your application will be medically underwritten and further medical evidence may be sought before a decision will be made on your application.Section 8: Preferential EntryIf you cannot tick Yes to all 5 boxes please proceed to complete Section 9 Medical and Other Information. Please tick to confirmI am under age 35*YesNoIn the past 12 months I have not been referred to or attended a consultant, specialist, hospital or clinic*YesNoI am not currently awaiting any medical appointment test or surgery or the results of any tests or surgery*YesNoIn the last five years I have not, because of a medical condition ...:... been refused or postponed insurance cover*YesNo... had insurance cover offered only if I paid an extra premium*YesNoIf you can tick all 5 boxes above please proceed to Section 11. - Declaration.Section 9: Medical QuestionsIn the last year have you:1. Been prescribed, advised to take or take any medication or treatment lasting more than two weeks including tablets, creams, inhalers, drops or sprays? (you can ignore any oral contraceptive treatment) **YesNoIn the last 5 years have you:2. Had any mental health condition requiring inpatient treatment or referral to a specialist or psychiatrist, including any eating disorder or an alcohol problem?*YesNo3. Had any medical tests, investigations or surgery?*YesNo4. Because of a medical condition: been refused or postponed insurance cover, had insurance cover offered only if you paid an extra premium, or had insurance over offered with one or more medical conditions excluded?*YesNoIn the last 10 years have you:5. Had diabetes, a stroke, or any problems with your heart or kidneys?*YesNo6. Had any form of cancer or a tumour or leukaemia?*YesNoAre you currently:7. Awaiting any appointment, test, surgery or investigation with your own doctor or any other medical professional?*YesNo8. Experiencing any symptoms for which you have not yet sought medical advice or treatment?*YesNoIf you have answered ‘yes’ to any of the questions above please provide details below or on a separate sheet. Please provide as much information as possible i.e. diagnosis, treatment, investigations carried out and results, what you have been told regarding your condition.Additional Information:Nature of IllnessDatesTreatment / InvestigationsName and address of doctor consulted1. Illness1. Date1. Treatment1. Doctor2. Illness2. Date2. Treatment2. Doctor3. Illness3. Date3. Treatment3. Doctor4. Illness4. Date4. Treatment4. Doctor5. Illness5. Date5. Treatment5. Doctor6. Illness6. Date6. Treatment6. Doctor7. Illness7. Date7. Treatment7. Doctor8. Illness8. Date8. Treatment8. DoctorSection 10: Contact DetailsFurther details via Medi-Phone call – from time to time, Irish Life may require more medical or risk-related information. If this is the case, you will be contacted by telephone by a nurse working for Morgan Ash Ltd. (specialist company who carry out the phone calls on Irish Life’s behalf) to obtain more information regarding your medical history. This will help Irish Life process your application more quickly. It is essential that you provide all requested information regarding your medical history. This telephone call will be recorded and will form part of your application for cover. For details of how the ‘Medi-Phone call’ works, please see Section 13 Medi-Phone: your questions answered. Contact Details - Please provide as many phone numbers as possible and your preferred contact timeHome NumberWork NumberMobile Number*Email Address*Preferred Contact Time*MorningAfternoonEveningSection 11: DeclarationWarning - 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. I declare that: 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, any information I give to a medical examiner acting for Irish Life and all terms and conditions given to me by Irish Life. I have read and understand the important information about my obligation to tell Irish Life about all material facts in connection with the application and I understand that if I do not tell Irish Life all material facts, this contract could be void. If this happens, I understand and acknowledge there will be no cover available to me under the scheme. Irish Life will not refund my premiums and will not pay a claim under the scheme. I also understand that I may encounter difficulty in obtaining cover elsewhere. I declare that all information, statements and answers I have provided, are true and complete. I understand that I must tell Irish Life in writing about any changes in my health, circumstances, or if any answers to the questions in this application form change between the time I applied for cover and the date my application is accepted.I understand that this plan will not start until Irish Life has accepted me for cover and I have paid the first payment. I understand that Irish Life can use my personal information for any subsequent applications to Irish Life. I confirm that I understand the scheme eligibility section of this application form. I understand that membership of this scheme is conditional upon my continued union membership and/or employment. I understand that it is a condition of membership that I accept that the Trustees may amend the terms of The CWU Additional Voluntary Contribution Life Assurance Plan or terminate the plan altogether and that decisions of the Trustees in such matters are binding on all members. • I confirm that I have received, read and understand the key features of the scheme booklet • I confirm I have read and understood the Medical and Other Important Information section • I declare that I am actively at work today, or capable of being actively at work today.* • I confirm I have been informed about the Irish Life Data Privacy Notice and where to find this. 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.Applicant's Signature*Warning: The current premium may increase after the next review of the scheme at 01/09/2022 *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 career break or other forms of unpaid leave are not considered 'actively at work' - Under age 60Section 12: Optional ConsentConsent to Sharing with Other Companies in the Irish Life Group*I agreeI don't agreeI 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 email@example.com or writing to Irish Life Data Protection Team. If you opt out we will keep a record of your instruction to opt out.Applicant's Signature*Section 13: Medi-Phone - Your Questions AnsweredWhat is Medi-Phone? Medi-Phone is an interview over the phone. We use it to gather medical or ‘risk-related’ information when you apply for cover. Risk-related information might include details of your current health, past medical history, family medical history, occupational risks and sports or hobbies. How does Medi-Phone work? All phone calls are made by qualified nurses who work for MorganAsh (a specialist company who are conducting the interviews on behalf of Irish Life). They will first ask you to confirm some personal information, as a security check and to ensure confidentiality and that you are comfortable to undertake the interview at that particular time. After this, they will ask you relevant questions to gather the health information we need. 1. Details of any medication you are currently taking (name and dosage). 2. Details of any past or present medical conditions suffered. 3. Details of any tests or investigations, e.g. blood pressure, cholesterol tests. You may like to phone your G.P. or whoever did these tests, to get the results. 4. You may be asked for your height and weight. If you do not know your weight, please try to weigh yourself prior to the interview. 5. It is helpful to think about your recent medical history, for example in the past three years, did you visit the doctor or have you missed any time off work? If so, why and what medication did you receive? The call will be recorded and will be a permanent part of your application for cover. Calls should take approximately 15 to 30 minutes.Once we have gathered the relevant details as part of the Medi-Phone call, a skilled Irish Life underwriter will assess the information and, in most cases, make a final decision on whether we can accept your application. Your financial advisor will then write to you to communicate this decision. In certain circumstances we may require some further medical evidence from your doctor and/or from yourself. You will be advised if this is necessary. A copy of the interview will be sent to you for your records. If you need to change anything, or would like to add anything to the report, you can make the amendment, sign it and return it to Irish Life in the Freepost envelope provided with the report. What are the advantages of Medi-Phone over getting the information by paper? 1. We tailor each interview to you and your personal circumstances making the process easier and quicker than completing a standard application form. 2. It may be more convenient for you. 3. We can get better quality information on your health history. What happens if I do not want to discuss my medical details over the phone? This is not a problem. Following a Medi-Phone call, if you are not happy providing your medical details over the phone, we will post you the relevant forms for your completion. You can then post these forms back to Halligan Insurances. If you have any questions in relation to this please contact Halligan Insurances on 01 879 7100.Section 14: Confirmation of Scheme MembershipYour cover will commence from the date Irish Life accepts your application. You will receive a formal acceptance letter confirming that you have been included as a member of the CWU AVC Life Assurance Plan. Irish Life will assess the potential risk of insuring you before membership of the Plan can be confirmed. This may involve attending for a medical examination. In a small percentage of cases membership of the CWU AVC Life Assurance Plan may be refused. In such cases you will receive a letter confirming that you have not been accepted in the Scheme. In other cases membership may be offered subject to the payment of an additional contribution. In these circumstances you can ask Irish Life to write to your GP with the reasons for their decision. Completed forms should be returned to: HALLIGAN INSURANCES, William Norton House, 575 NCR, Dublin 1. Irish Life Assurance plc 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 Corporate Business, Lower Abbey Street, Dublin 1, Ireland. T: 01 704 2000 • F 01 704 1905Section 15: Salary Deduction Mandate - Please SignThe Trustees of the CWU AVC Life Assurance Plan have appointed Halligan Insurances to collect premiums from plan members on the Trustees behalf and to submit these to the underwriter of the Plan. The underwriter of the plan, as at 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/Employer's Name*Office section InCWU Branch*Employer's Staff Number*Employee's DOB*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Employee's Name*Contact Number*Employee's Email*Please deduct from my salary the appropriate contribution under the CWU AVC Life Assurance Plan. 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's Signature*UserIPEntry Hash ValueDigitalTagSubmitted DateHalligan Life & Pensions Ltd t/a Halligan Insurances, Good Insurance is regulated by the Central Bank of Ireland. Warning: The current premium may increase after the next review of the scheme at 01/09/2022.Digital Signature Agreement* I understand and agree that my digital signature is legally binding.