CWU Life & SIC Application | Halligan Insurances

- Unique ID
- Prior to completing this form please read each question. Please ensure that you fully understand all the questions and notes.
- Choose your CWU Cover
- Select the cover that you and/or your Partner wish to apply for:*
  - Select All
  - Member Specified Illness - Scheme No.26209
  - Spouse Specified Illness - Scheme No.26209
  - Member AVC Group Life - Scheme No.26206
  - Spouse AVC Group Life - Scheme No.26208
- Table Break
- ** NB The Member needs to be in the same Scheme or be applying to enrol, in order for the Spouse/Civil Partner to be eligible.
- NB The Member needs to already joined consent*
  I understand*
- Table Break
- 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.
- This online form is to be completed in separate sections relating to the cover chosen above. It must be completed by the CWU Member and Spouse/Partner independently. This form can be saved and completed at a later date, without losing any information provided you click on the "Save and Continue Later" link, which is shown at the bottom of each page.
- This online form is to be completed in separate sections relating to the cover chosen above. It must be completed by the CWU Member and Spouse independently.*
  I understand*

Save and Continue Later

- Section 1: Eligibility (Member)
- If 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 voluntary.
- Section 1: Eligibility (Partner)
- If you meet the following conditions, you are eligible to join the Plan.
  • You are a Spouse/Civil Partner of an active in Benefit member of the CWU (ie a member working for an Employer of the plan)
  • Your Spouse/Civil Partner meets the eligibility to be a member of the Union member Plan and has joined or is joining at the same time.
  • Your Spouse/Civil Partner meets the eligibility if the Member is already in the scheme or is applying at the same time. • You are under age 60
- * 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.
- Membership of the Plan is voluntary.
- Table Break
- Member Eligibility Agreement
  I agree (Member)
- Partner Eligibility Agreement
  I agree (Partner)
- Table Break

Save and Continue Later

- Section 2: Member Details
- Title*
  - Mr
  - Mrs
  - Miss
  - Ms
  - Other
- Other*
- First Name*
  Please use both the first name and surname in your employee records
- Surname*
- Date of Birth*
- Gender*
  - Male
  - Female
- Marital Status*
- Member Age
- All Applicants must be over 18 and under 60 years old
- Address*
- Staff Number*
- Email Address*
- Mobile Number*
- Home Number
- Member GP Details
- Please 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 Name
- Previous GP Address
- Table Break

Save and Continue Later

- Section 2: Partner Details
- Title*
  - Mr
  - Mrs
  - Miss
  - Ms
  - Other
- Other*
- First Name*
  Please use both the first name and surname in your employee records
- Surname*
- Date of Birth*
- Gender*
  - Male
  - Female
- Spouse Age
- All Applicants must be over 18 and under 60 years old
- Use Member Contact Details
  - Use Member Contact Details
- Email Address*
- Mobile Number*
- Partner GP Details
- Use Member GP Details
  - Copy from Member GP Details
- Please 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 Name
- Previous GP Address
- Table Break

Save and Continue Later

- Section 3: 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 [email protected] 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
- Partner Consent to Sharing with Other Companies in the Irish Life Group*
  - I agree
  - I don't agree

Save and Continue Later

- Section 5: Medical and Other Information
- Your 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.
- Member Acknowledgment*
  I understand (Member)*
- Partner Acknowledgment*
  I understand (Partner)*

Save and Continue Later

- Section 7: Medi-Phone Information
- Further 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. (a 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 click
  >>> HERE <<<
- Please select your preferred contact time below
- Member Preferred Contact Time*
  - Morning
  - Afternoon
  - Evening
- Partner Preferred Contact Time*
  - Morning
  - Afternoon
  - Evening
- Normally, you will be contacted within a couple of days or so of Halligan Insurances submitting your application form to Irish Life. If, when you are called, it is not a convenient time, then just ask to re-arrange to a more convenient time. If you have not been contacted within 3 days, or you have been away or out of touch you may like to phone MorganAsh on Free-phone 1800 80 50 22. The interview can be undertaken between 9am and 9pm Monday to Saturday (excluding bank holidays and public holidays). If you have call barring on your phone, please arrange to allow MorganAsh to phone you, or you may like to call them on the above number. It is important that you are in a confidential situation and have the time to spare to undertake the interview. MorganAsh will not undertake the interview if you are driving.

Save and Continue Later

- Section 8: Salary Deduction Mandate
- The 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 In
- 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
  I agree (Member)

Save and Continue Later

- CWU Life Assurance Plan 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 01/09/2022.
- 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.
- *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
- Any words in the singular also mean the plural as applicable (e.g. ‘I’ means ‘we’ and ‘my’ means ‘our’ etc.)
- Declaration
- 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, a member of CWU, (or a spouse/civil partner/partner of a member of CWU) confirm that 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 and/or The CWU Spouses/Civil Partners Plan or terminate the plans 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, the Member 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.
- Member Declaration*
  I agree (Member)*
- Partner Declaration*
  I agree (Partner)*
- CWU SPECIFIED ILLNESS COVER PLAN Declaration
- Warning: The current premium may increase after the next review of the Specified Illness Cover scheme at 01/06/2021.
- Any words in the singular also mean the plural as applicable (e.g. ‘I’ means ‘we’ and ‘my’ means ‘our’ etc.)
- 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 CWU, (or a spouse/civil partner/partner of a member of CWU) confirm that I have read and fully understand the corresponding booklet in relation to CWU 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.
- Member Declaration*
  I agree (Member)*
- Member Declaration*
  I agree (Partner)*
- Table Break
- Application Declaration Signatures
- Member's View
- Member Declaration Signature*
- Member Digital Signature Agreement*
  I understand and agree that my digital signature is legally binding.*
- Partner's View
- Partner Declaration Signature*
- Spouse Digital Signature Agreement*
  I understand and agree that my digital signature is legally binding.*
- Table Break
- Click Submit to send Application forms to Halligan Insurances. It may take a minute for the applications to send.
  Please don't close or click back on your browser after clicking Submit.
  A confirmation page will be displayed when completed.
- Halligan Life & Pensions Ltd t/a Halligan Insurances, Good Insurance is regulated by the Central Bank of Ireland.
- UserIP
- Submitted Date
- Entry Hash Value Member
- Entry Hash Value Partner
- DigitalTag_Member
- DigitalTag_Partner

Save and Continue Later

Upload Your Profile

Step 1 of 14 - Choose Cover

Choose your CWU Cover

IMPORTANT DOCUMENTS

Table Break

Table Break

Section 1: Eligibility (Member)

Section 1: Eligibility (Partner)

Table Break

Table Break

Section 2: Member Details

Member GP Details

Table Break

Section 2: Partner Details

Partner GP Details

Table Break

Section 3: Optional Consent

Section 4: CWU Member Employment & Cover

Table Break

Member Life Cover Selected

Member Life Cover Selected

Member Life Cover Selected

Table Break

Partner Life Cover Selected

Partner Life Cover Selected

Partner Life Cover Selected

Table Break

Member Specified Illness Cover Selected

Member Specified Illness Cover Selected

Member Specified Illness Cover Selected

Table Break

Partner Specified Illness Cover Selected

Partner Specified Illness Cover Selected

Partner Specified Illness Cover Selected

Table Break

Table Break

Table Break

Section 5: Medical and Other Information

Section 6a: Preferential Entry (Member)

Medical Questions (Member)

Section 6b: Preferential Entry (Partner)

Medical Questions (Partner)

Section 7: Medi-Phone Information

Section 8: Salary Deduction Mandate

CWU Life Assurance Plan Declaration

CWU SPECIFIED ILLNESS COVER PLAN Declaration

Table Break

Application Declaration Signatures

Member's View

Partner's View

Table Break