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Apply online for CWU Member Life Cover

(Children are insured from birth to age 24 in either scheme* at no additional cost)
*maximum payment of €10,000 in respect of Life Cover Benefit for Children.

Prior to completing this form 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 the website at irishlifecorporatebusiness.ie or you can ask for a copy.

Section 1: Eligibility

Please read the criteria below to ensure that you are eligible to apply for cover under this Plan.
To be eligible to apply for membership of this plan Life Assurance Plan with this form you must be:
> Under age 60
> 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 medically 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’

> Are not currently absent from work due to experiencing COVID-19 symptoms i.e. continuous cough, a high temperature or breathing difficulties, testing positive for COVID-19, being advised to have a COVID-19 test or waiting on a COVID-19 test result.

Membership of the Plan is voluntary.

Member Eligibility Agreement*

I agree (Member)*

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Section 2: Member Details

Title*

Mrs

Miss

Other

Other*

First Name*

Surname*

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

Marital Status*

Gender*

Male

Female

Date of Birth*

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Member Age

Occupation*

Staff Number*

Applicants must be over 18 and under 60 years old

Address*Please enter your full address!

Email Address*

Mobile Number*

Home Number

Doctor Details

Depending on the information you give us in your answers to the Medical questions below, Irish Life may ask for further medical information from you and/or you GP or may ask you to have a tele-interview with a nurse. We will explain the tele-interview process in more detail in Section 9.

a) Please give the name and address of your General Practitioner (GP)

Name of GP*

Address of GP*

b) If you have changed doctor in the last 2 years, please give the name and address of that GP

Previous GP Name

Previous GP Address

Member Preferred Contact Time*

c) If Irish Life asks you to have a tele-interview, what time of day would you prefer to be contacted?

Morning

Afternoon

Evening

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Section 3: CWU Member Employment & Cover

Employer*

An Post

Eir

Vodafone

Other

Other Employer*

Frequency of Pay*

Weekly

Fortnightly

Monthly

Please choose your payment preference.*

by Salary Deduction

by Direct Debit

Please choose your payment preference.*

by Direct Debit

CWU Branch*

Office Address*

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CWU LIFE COVER BENEFITS

CWU Life Cover Plan – Table 1

AGE	CWU AVC LIFE ASSURANCE PLAN MEMBER (EMPLOYED)	SPOUSE/CIVIL PARTNER
18-34	€100,000	€100,000
35-44	€100,000	€100,000
45-54	€85,000	€75,000
55-64	€75,000	€65,000
Children are insured from Birth to age 24 for €10,000*

*Claim Benefit paid based on your age at the time of the claim.

Member Life Cover Selected

Member Life Premium

Price:

(Your premium increases to the normal rate at age 35)

Please refer to the explanatory booklet. Your cover is related to your age at date of claim.

Warning: The current premium may increase after the next review of the scheme.

Section 4: Medical and Other Information

Please read the question below and ensure that you fully understand each question before answering it.

Your personal health information

In addition to our Privacy Notice, the following is more detail relating to your personal health information that we collect and use in connection with this application. 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.

Relevant Information

When deciding whether to insure you and when setting the terms and conditions, Irish Life will rely on the information you have given. You must answer all questions that Irish life have asked in this form honestly and with reasonable care. Where Irish Life asks you to answer a specifc question, the subject matter of the question is relevant to the risk Irish Life is being asked to accept. If your answers are not true and complete, Irish Life may be entitled to:

- Cancel your membership and benefts under the Scheme without a return of premium.
- Refuse a claim.
- Reduce the amount of any claim.
- Reduce the amount of cover and/or.
- Treat the policy as if it had been entered into on different terms.

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 relating to any of the questions asked in this section, you should disclose this information in the box provided in this section. Irish Life may also contact you to ask you for further information on your answers or as part of any subsequent claim. Irish Life may rely on the information you provide and we may not automatically clarify or confrm any information you provide. If your application for cover is accepted, Irish Life will issue you an acceptance letter. In this letter, Irish Life will ask you to advise if there has been any change to your health, circumstances, or answers to any of the questions provided in your application form. If there has been any changes between the date of your application and the date that you are accepted into the Scheme, this may affect the original acceptance terms issued to you.

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)*

Section 5: Preferential Entry

Preferential Entry means that once you tick Yes to confirm all of the statements in this Section, your application will be accepted based on this declaration. If you answer No or if you have any doubt and/or question regarding your ability to complete the preferential declaration, then you will be required to answer medical questions on the next page.

Please tick to confirm:

I am under age 35*

Yes

In the past 12 months...*

In the past 12 months, I have NOT been referred to or attended a consultant, specialist, hospital or clinic

Yes

I am NOT currently...*

I am NOT currently awaiting any medical appointment test or surgery or the results of any tests or surgery

Yes

In the last five years, I have NOT, because of a medical condition ...

... been refused or postponed insurance cover*

Yes

... had insurance cover offered only if I paid an extra premium*

Yes

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Medical Questions

You must answer each of the medical questions below. Your application will be medically underwritten and further medical evidence may be sought before a decision will be made on your application.

If you answer ‘Yes’ to any of the questions below please provide as much information as possible i.e. diagnosis, treatment, investigations carried out and results, what you have been told regarding your condition.

In the last year have you:

1. Been prescribed...*

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)

Yes

Please fill details below

1. Date*

1. Illness*

1. Doctor*

1. Treatment*

In the last 5 years have you:

2. Had any mental health condition...*

2. Had any mental health condition requiring inpatient treatment or referral to a specialist or psychiatrist, including any eating disorder or an alcohol problem?

Yes

Please fill details below

2. Date*

2. Illness*

2. Doctor*

2. Treatment*

3. Had any medical tests, investigations or surgery?*

Yes

Please fill details below

3. Date*

3. Illness*

3. Doctor*

3. Treatment*

4. Because of a medical condition...*

4. 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?

Yes

Please fill details below

4. Date*

4. Illness*

4. Doctor*

4. Treatment*

In the last 10 years have you:

5. Had diabetes, a stroke...*

5. Had diabetes, a stroke, or any problems with your heart or kidneys?

Yes

Please fill details below

5. Date*

5. Illness*

5. Doctor*

5. Treatment*

6. Had any form of cancer or a tumour or leukaemia?*

Yes

Please fill details below

6. Date*

6. Illness*

6. Doctor*

6. Treatment*

Are you currently:

7. Awaiting any appointment...*

7. Awaiting any appointment, test, surgery or investigation with your own doctor or any other medical professional?

Yes

Please fill details below

7. Date*

7. Illness*

7. Doctor*

7. Treatment*

8. Experiencing any symptoms...*

8. Experiencing any symptoms for which you have not yet sought medical advice or treatment?

Yes

Please fill details below

8. Date*

8. Illness*

8. Doctor*

8. Treatment*

Section 7: Salary Deduction Mandate

The Trustees of the CWU AVC Life Assurance Plan have appointed Halligan Insurances to collect the appropriate premiums from plan members on the Trustees behalf and to submit these to the underwriter of the Plan. The underwriter of the plan, as of 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

Staff Number*

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)*

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.

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

Life Declaration

You must tick each statement to confirm you have read and understand the Declaration.

declaration_q1*

I understand that this application form along with supplementary information given to Irish Life will form my application for cover.