CWU PA Application Form | Halligan Insurances

- 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 Apply
- Choose 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: € 2.48
- Individual Cover
  Price: € 1.65
- Application Date*
- Phone Number*
- Number of Children*
- 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 authority
  I 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 AmTrust International Underwriters DAC has notified me to the contrary, the deductions are subject to the acceptance of risk by AmTrust International Underwriters DAC. 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 premiums
- NOTE:
  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
  € 0.00
- Data Protection Notice
  Halligan Life & Pensions Limited (the administrator) and AmTrust International Underwriters DAC (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.
- Digital Signature Agreement*
  I understand and agree that my digital signature is legally binding.
- Member's Signature*
- Halligan Life & Pensions Ltd t/a Halligan Insurances, Good Insurance is regulated by the Central Bank of Ireland.
- AddressLine
- Submitted Date
- UserIP
- Entry Hash Value
- DigitalTag

Upload Your Profile

NOTE:

Please complete the salary deduction authority

NOTE:

Data Protection Notice