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Apply online for CWU Specified Illness Cover for yourself & your partner

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.

Select the boxes for Cover that you and/or your Partner wish to apply for:*

Member Specified Illness

Partner Specified Illness

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Spouse SIC Only Joining Section

** NB In order for the Spouse/Civil Partner to be eligible, the Member needs to be in the SIC Scheme or be applying to enroll.

NB The Member needs to already joined consent*

I understand*

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Member Details Section

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

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All Applicants must be over 18 and under 60 years old

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Occupation*

Staff Number*

Address*Please enter your full address!

Email Address*

Mobile Number*

Home Number

Partner Details Section

Partner is defined as a spouse or civil partner or a person living in a spousal type relationship with the member for 12 months or more at the date application for cover is made.

Note: If you are including your partner, you must make them aware that you are providing Irish Life with their details. You must also inform them about the Irish Life Data Privacy Notice and where to find it.

Please complete the following details if you wish to cover your partner under the Plan.

Title*

Mrs

Miss

Other

Other*

First Name*

Surname*

Marital Status*

Gender*

Male

Female

Date of Birth*

Occupation*

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Spouse Age

All Applicants must be over 18 and under 60 years old

Use Member's Contact Details

Use Member Contact Details

Mobile Number*

Email Address*

To be completed by those who want their partner covered: I wish to include my partner for cover under the CWU Group Specified Illness Cover (SIC) plan. This is referred to as Partner throughout the rest of this form. I understand that my partner, as stated above, is covered under the plan, unless I notify my employer of a change in circumstances.

Note: A person can become a member of the CWU Group Specified Illness Cover (SIC) Plan either as a CWU member or the partner of a CWU member, but not both i.e. only one amount of Benefit will ever be paid to, or in respect of any given person under the CWU Group SIC Plan, even if that person is both a CWU member and also the partner of another CWU Member.

Member Signature for Partner*

Member's Signature

Cover Options Section

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 SPECIFIED ILLNESS COVER BENEFITS

CWU SIC Cover Plan – Table Cover

AGE OF MEMBER & SPOUSE	FULL BENEFIT	COST FOR MEMBER & SPOUSE
Age 18-34	€55,000 SIC	€2.00 per week
Age 35-44	€45,000 SIC	€3.94 per week
Age 45-54	€20,000 SIC	€3.94 per week
Age 55 to 66	€15,000 SIC	€3.94 per week
Children’s benefit aged 30 days to 25 years	€20,000 SIC €10,000 Life Cover *	Included

* Children’s Life Cover is only available under this plans for member who do not have Life Cover under the CWU Life Plan. Please see scheme explanatory booklet for full details.

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

Member Specified Illness Cover Selected

Member SIC Premium

Price:

Mem SIC Cover Option

Price:

Partner Specified Illness Cover Selected

Spouse SIC Premium

Price:

Spo SIC Cover Option

Price:

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(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.

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Application Declaration Section

Warning: The current premium may increase after the next review of the Specified Illness Cover scheme at 01/06/2023.

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.)

Specified Illness Declaration (SIC)

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

I understand and agree that my contract...*

I understand and agree that my cover 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 Agree

I confirm that I am eligible to join...*

I confirm that I am eligible to join this plan as 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. I also confirm that I understand the key features of the Plan and accordingly I now apply to join this Plan.

I Agree

I understand that where I have a medical history...*

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 Agree

I declare that all information...*

I declare that all information, statements and answers I have provided, are true and complete, and answered honestly and with reasonable care.

I Agree

I understand that Irish Life can use...*

I understand that Irish Life can use my personal information for any subsequent applications to Irish Life.

I Agree

I confirm I have been informed...*

I confirm I have been informed about the Irish Life Data Privacy Notice and where to find it and where I am including my partner I have informed them about the Irish Life Data Privacy Notice and where to find it.

I Agree

Member SIC Declaration Signature*

Member Signature - Declaration Agreement

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Member Consent Declaration*

I agree (Member)*

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Partner SIC Declaration Signature

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Spouse Electronic Signature Agreement

I understand and agree that my electronic signature is legally binding.

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Partner Consent Declaration*

I agree (Partner)*

Optional Consent Section

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 cbconsentoptout@irishlife.ie 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

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 Signature*

Member Signature - SD Agreement

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Member SD Agreement

I agree (Member)

Electronic Signature Agreement

Member Electronic Signature Agreement*

I understand and agree that my electronic signature is legally binding.*

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Submit Section

Click Submit to send Application forms to Halligan Insurances.
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.

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UserIP

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Submitted Date

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Entry Hash Data

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Entry Hash Value

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DigitalTag_Member

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Completed SIC Application

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CheckSum SIC

Upload Your Profile

Apply online for CWU Specified Illness Cover for yourself & your partner

Spouse SIC Only Joining Section

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Member Details Section

Hide Age Validation on Spouse Only Cover

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Partner Details Section

Cover Options Section

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Member Specified Illness Cover Selected

Partner Specified Illness Cover Selected

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Application Declaration Section

Optional Consent Section

Salary Deduction Mandate

Electronic Signature Agreement

Submit Section

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