"*" indicates required fields Unique ID Permanent Member / Partner Children Accidental Death €70,000 €10,000 Permanent Total Disablement €70,000 €35,000 Loss of Limbs / Sight €70,000 €35,000 Loss of Speech €70,000 €35,000 Loss of Hearing up to €70,000 up to €35,000 Other Permanent Disabilities (continental scale) up to €70,000 up to €35,000 Hospitalisation (payable after 24 hours up to 26 weeks) €300 per week €150 per week Fracture to Arms €750 €375 Fracture to Legs €1500 €750 Burns covering up to 27% or more of the body up to €6,000 up to €6,000 Temporary Total Disablement (payable after 26 weeks for up to 2 years, or for back and/or neck injuries, including whiplash, benefit is payable after 52 weeks) this benefit is not operative if retired or unemployed. €300 per week Nil NOTE:This is just a summary, please refer to the explanatory booklet for more details. T&C applies. Children are free and are covered from age 1 up to age 23. Exclusions ApplyImportant DocumentsPolicy DocumentHalligan's Terms and ConditionsHiddenDocuments End SectionChoose your Rate* Family: €2.48 per week(€129 annual premium) Member, Spouse, Partner & Children Individual: €1.65 per week (€86 annual premium) Member only Family Cover Price: Individual Cover Price: Application Date* Phone Number* Number of Children*Email* Enter Email Confirm Email Our Data Protection Notice for this product is detailed overleaf. Please read this carefully. By signing this form I confirm that I have read and understood the Data Protection Notice.Member's Name* Member's DOB* Partner's Name Partner's DOB Member's Address* Street Address Address Line 2 City County Postal Code Please complete the salary deduction authorityI hereby authorise my employer to make the necessary deductions from my salary or wages for the specific purposes of paying for my membership of the CWU Family Personal Accident Scheme. Such deductions are being made solely for my convenience and may be discontinued at any time. Until such time as AIG has notified me to the contrary, the deductions are subject to the acceptance of risk by AIG. I undertake to notify Halligan Insurances if for any reason policy deductions do not occur as agreed. I understand that cover is subject to the continuation of payment of the premiumsNOTE:If you are not employed by Eircom, An Post or Vodafone please still complete the Salary Deduction mandate and a Direct Debit form will be issued thereafter.Name of Employer* Staff Number* Name of CWU Branch* Deduction Amount Data Protection Notice Halligan Life & Pensions Limited (the administrator) and AIG (the insurer) (“We”/“Us”), as Data Controllers, are committed to protecting and respecting your privacy in accordance with the current Data Protection Legislation. We may use the personal data held about you for the purposes of providing insurance, handling claims and any other related purposes, for offering renewal, research or statistical purposes, to safeguard against fraud and money laundering, to meet general legal or regulatory obligations and to provide you with information, products or services that you may request. You understand that we may also need to obtain and use sensitive information (such as health information) in carrying out these tasks, and without this information, a policy or claim may not be able to be processed. We may use and share your information with our group companies, affinity partners, brokers, agents, third party administrators, service providers, reinsurers, credit agencies, fraud detection agencies, loss adjusters, accountants, regulatory authorities, and as may be required by law. Your data may be transferred to destinations outside the European Economic Area (“EEA”), and where this occurs it will be treated securely and in accordance with the Legislation. Details of other insurers and third parties are available on request. You have the right to ask us not to process your data for marketing purposes, to see a copy of the personal information held about you, to have your data deleted (subject to certain exemptions), to have any inaccurate or misleading data corrected or deleted, to restrict processing, to ask us to provide a copy of your data to any controller and to lodge a complaint with the local data protection authority. Your data will not be retained for longer than is necessary and will be managed in accordance with data retention policies unless we are required to retain the data for a longer period due to business, legal or regulatory requirements. Member's Signature*Member Electronic Signature AgreementElectronic Signature Agreement* I understand and agree that my electronic signature is legally binding.*Marketing Consent Please tick this box to allow us to contact you about discounts, special offers and information by post, email, SMS, phone and other electronic means.Halligan Life & Pensions Ltd t/a Halligan Insurances, Good Insurance is regulated by the Central Bank of Ireland.HiddenAddressLine HiddenSubmitted Date HiddenUserIP HiddenEntry Hash Value HiddenDigitalTagHiddenCompleted Application Form HiddenChecksum EmailThis field is for validation purposes and should be left unchanged.