ISME Life Application | Halligan Insurances

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Prior to completing this form please read each question. Please ensure that you fully understand all the questions and notes.

IMPORTANT DOCUMENTS

Plan Booklet

Halligan's Terms of Business

Irish Life Terms of Business

Eligibility Rules

To be eligible to apply for membership of the Life Assurance Scheme with this form you must be:
• An employee of companies affiliated to ISME
• Under age 60
• Working for 8 hours or more per week and either
• Employed on a permanent full-time basis or
• Commenced a contract of definite duration (if you are in a temporary position your contract must be at least 12 months’ duration. Cover will only continue as long as you remain an employee as outlined above) or
• Working continuously for the past 6 months (if you are in a temporary position you must be actively working now).

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.

Section 1: Personal Details

Title*

Mrs

Miss

Other

Other*

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

Applicant's Name*

First Name Surname

Home Address*

Street Address Address Line 2 City County ZIP / Postal Code

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Home Address*

Please provide your mobile phone number and your email address, both are needed in case we need to contact you regarding your application.

Mobile Number*

Work Number

Home Number

Email*

Date of Birth*

DD slash MM slash YYYY

Gender*

Male

Female

Section 2: Employment Details

Employer Name*

Employer Address*

Percise Occupation*

Date employment started*

DD slash MM slash YYYY

Please choose one of the following:*

New Entrant

Existing Member

Current benefit? €*

Please enter a number greater than or equal to 0.

I wish to have Life Assurance cover of:

€50,000

€75,000

€100,000

Important:The maximum amount of lump sum death benefit Revenue will permit to be paid is four times salary, taking into account all similar benefits arising under retirement or death benefit insurance.

Section 3: 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-inter view with a nurse. We will explain the tele-inter view process in more detail in Section 6

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.

Name of previous GP

Address of previous GP

c) If Irish Life asks you to have a tele-inter view what time of day do you prefer to be contacted?

Perferred contact time*

Morning

Afternoon

Evening

Section 4: Medical and Other Important information

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

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.

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 specific 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 benefits 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 confirm 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 disclose 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 disclose when required by the medical questions, 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.

Medical questions

If you have answer ‘yes’ to any of the questions below, then please provide details in the field directly below each question.
(the field only shows if you select 'yes')

Q1. In the last year, have you been prescribed, advised to take or taken any medication or treatment lasting for than two weeks including tablets, creams, inhalers, drops or sprays?*

(You can ignore any oral contraceptive treatment).

Yes

Q1 Nature of Illness*

Nature of Illness

Q1 Name and Address of Doctor*

Name and Address of doctor consulted

Q1 Any Restrictions on daily activities*

Any Restrictions on daily activities

Q2. In the last 5 years, have you had any mental health condition requiring inpatient treatment or Yes No referral to a specialist or psychiatrist, including any eating disorder or an alcohol problem?*

Yes

Q2 Nature of Illness*

Nature of Illness

Q2 Name and Address of Doctor*

Name and Address of doctor consulted

Q2 Any Restrictions on daily activities*

Any Restrictions on daily activities

Q3. In the last 5 years, have you had any medical tests, investigations or surgery?*

Yes

Q3 Nature of Illness*

Nature of Illness

Q3 Name and Address of Doctor*

Name and Address of doctor consulted

Q3 Any Restrictions on daily activities*

Any Restrictions on daily activities

Q4. In the last 5 years, have you, because of a medical condition: been refused or postponed Yes No insurance cover, had insurance cover offered only if you paid an extra premium, or had insurance offered with one or more medical conditions excluded?*

Yes

Q4 Nature of Illness*

Nature of Illness

Q4 Name and Address of Doctor*

Name and Address of doctor consulted

Q4 Any Restrictions on daily activities*

Any Restrictions on daily activities

Q5. In the last 10 years, have you had diabetes, a stroke, or any problems with your heart or kidneys?*

Yes

Q5 Nature of Illness*

Nature of Illness

Q5 Name and Address of Doctor*

Name and Address of doctor consulted

Q5 Any Restrictions on daily activities*

Any Restrictions on daily activities

Q6. In the last 10 years, have you had any form of cancer or a tumour or leukaemia?*

Yes

Q6 Nature of Illness*

Nature of Illness

Q6 Name and Address of Doctor*

Name and Address of doctor consulted

Q6 Any Restrictions on daily activities*

Any Restrictions on daily activities

Q7. Are you currently awaiting any appointment, test, surger y or investigation with your own doctor Yes No or any other medical professional? If you answer ‘yes’ to this question, Irish Life may not be able to make a decision on your application until the medical investigations are complete and the results are available to Irish Life.*

Yes

Q7 Nature of Illness*

Nature of Illness

Q7 Name and Address of Doctor*

Name and Address of doctor consulted

Q7 Any Restrictions on daily activities*

Any Restrictions on daily activities

Q8. Are you currently experiencing any symptoms for which you have not yet sought medical advice or treatment?*

Yes

Q8 Nature of Illness*

Nature of Illness

Q8 Name and Address of Doctor*

Name and Address of doctor consulted

Q8 Any Restrictions on daily activities*

Any Restrictions on daily activities

Section 5: Declaration - You must read this carefully before signing

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.

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

1. *

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

I agree

2. *

I understand and agree that the information that I have provided in this application form , along with any supplementar y questions answered, any statements made to Irish Life in writing or by telephone (which will be recorded in writing) and/or any information provided to Irish Life on my behalf from a GP, hospital, consultant or heath professional is material to the decision of Irish Life to allow my membership to the scheme and is relied on by Irish Life for setting my acceptance terms for membership into this scheme.

I also understand that my membership into this scheme with Irish Life comprises of my acceptance terms and the following scheme documents:
> The Scheme policy document.
> The terms and conditions included in the Scheme Summary Booklet and. > Any Scheme Review Booklets following a review.

I agree

3. *

I also understand as this is a reviewable scheme the terms and conditions for the scheme may change at the subsequent rate reviews.

I agree

4. *

I have read and understood the Medical and other important information section about my obligation
to answer all questions asked by Irish Life in this application form and in connection with the application. I also understand that if I do not answer these questions honestly and with reasonable care, Irish Life may be entitled to: > Cancel my membership without return of premium.
> Refuse my claim.
> Reduce the amount of any claims and or. > Reduce the amount of cover.
> Treat my insurance as if it was entered into on different terms

I agree

5. *

I also understand that I may encounter difficulty in obtaining cover elsewhere.

I agree

6. *

I have read over the answers to all the questions on this form and declare that all answers (including any answers written down for me) are true and complete. I declare that I have answered all of the questions in this form honestly and with reasonable care.

I agree

7. *

I understand that if my application for cover is accepted, Irish Life will issue me an acceptance letter. In this
letter, Irish Life will ask me to advise if there has been any change to my health, circumstances, or answers to
any of the questions provided in my application form. If there has been any changes between the date of my application and the date I am accepted into the Scheme, this may affect the original acceptance terms issued to me.

I agree

8. *

I understand that membership into this scheme will not start until Irish Life has accepted me for cover and
I have paid the first payment. I understand that Irish Life may use my personal information when underwriting any subsequent applications for cover with Irish Life.

I agree

9. *

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.

I agree

9. *

I confirm that I have completed and understand the Scheme eligibility criteria. I confirm that all answers provided by me in this regard are answered honestly and with reasonable care and I understand that my cover is dependent upon continuing to satisfy the eligibility conditions of the Scheme. I also confirm that I am actively at work today and that I understand the meaning of actively at work today* as defined below.

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’ means that you:
> Are working your normal contracted number of hours.
> Have not received medical advice to refrain from work; and
> Are medically capable of fully performing the normal duties associated with your occupation.
> Are not currently absent from work due to COVID-19.
Those on career break, carer’s leave, parental leave, parents leave or other forms of unpaid leave are not considered ‘actively at work’.

I agree

10. *

I understand that it is a condition of membership that I accept that the Scheme is a reviewable group scheme and that at the next review date the terms of the Scheme may be amended or terminated altogether. I also understand the Scheme owner’s decisions in such matters, as agreed with Irish Life are binding on all members of the Scheme.

I agree

11. *

I confirm I have been informed about Irish Life’s Data Privacy Notice and where to find this.

I agree

7. Applicant's Signature*

Applicant’s Signature *

7. Signed Date*

Signed Date *

Electronic Signature Agreement

Electronic Signature Agreement*

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

Please ensure all details entered are correct prior to submitting!

Section 6: Tele-interview - Your Questions Answered

Why are Tele-Interviews used?

You may be contacted by telephone by a qualified nurse working for MorganAsh Ltd (a specialist company that carries out the phone calls on Irish Life’s behalf ) to obtain information on your present health, lifestyle, occupation, and the medical history of you and your family. Irish Life engages MorganAsh to carry out these interviews for them and the information gathered is only used by Irish Life and no other organisation has access to this.

Tele-interviews are used because:

- They enable Irish Life to tailor medical questions to each applicant.
- They enable Irish Life to obtain a clear understanding of your health in order to risk assess your application more quickly and offer you the best possible terms in insurance.
- Many applicants find them more convenient than attending a medical examination.

The information you provide will be treated in the strictest confidence, and will be used only in the assessment of your application or in the event of a claim. With this in mind, the nurse will ask you to confirm your personal information, as a security check and to ensure confidentiality and that you are comfortable to undertake the inter view at that particular time. After this, they will ask you relevant questions required to process your application.

Instruction

It is essential that you provide all requested information regarding your medical history. This telephone call will be recorded. It will form part of your application for cover and, if accepted, will form the basis of your insurance contract with Irish Life along with any other medical information obtained by Irish life. Therefore, all the questions should be answered fully and honestly, as failure to do so could invalidate your cover and any future claims.

When will the tele-interview take place?

You will be contact normally within a day or so of Halligan Insurances submitting your application form to Irish Life to arrange a suitable time for your inter view. 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 working days, or have been away or out of touch you may like to phone MorganAsh on free-phone 1800 80 50 22. If you have call barring on your phone please arrange to allow MorganAsh to phone you, or you like to call them on the above number.

When you schedule a time for your inter view, you will be given an hour’s time slot and you should get a call in the first 30 minutes of this hour. If you are not free to answer the questions when called, the nurse will be happy to arrange a more suitable time for the interview to take place.

The nurses are able to undertake interviews from:
- 9am to 9pm Monday to Thursday.
- 9am to 7pm on Fridays.
- 10am to 2pm on Saturdays.

It is important that you are in a confident environment and able to speak freely and have the time to spare to complete the inter view. The inter view takes on average 30-60 minutes to complete. MorganAsh will not complete an inter view if you are driving.

What do I need to prepare?

If a Tele-Inter view is deemed necessary by Irish Life then you application for insurance cannot be processed until the interview has taken place. To prepare for your interview, please take some time to gather the following information and have this to hand when you receive the call:

- Details of any medication you are currently taking(including name and dosage).
- Details of any past or present medical condition suffered (other than ver y minor ailments such as the common cold).
- Details of any tests or investigations, eg blood pressure, cholesterol tests.
- Details of any serious conditions, such as cancer, heart attack, stroke, suffered by a member of your immediate family (your mother, father, brothers or sisters).
- MorganAsh will ask for your height and weight. If you do not know you weight, please tr y and weigh yourself prior to the interview.
- It is helpful to think about your recent medical history, for example, in the past few years, did you visit the doctor or have you missed any time off work? If so, why and what medication did you receive.

What if I do not wish to discuss my medical details over the phone?

If you are not happy providing your medical details over the phone, please advise MorganAsh when they call you or contact Irish Life who will post you the relevant forms for your completion instead. You can then post these forms back to Irish Life’s Chief Medical Officer using the pre-paid envelope provided with the forms.

What happens after the Tele-interview?

You will be sent a transcript of the call to check and ensure that the information is complete and accurate. Although a little time consuming, it is in your best interest to undertake this task with due care. If you are aware of inaccurate or incomplete details or of any changes required to the report, you are required to amend the transcript and return it to Irish Life.

Section 7: Conﬁrmation of Scheme Membership

Irish Life will assess the potential risk of insuring you and then make a decision on your application. This may involve attending for a medical examination. Your application may be:

> Accepted - If you are accepted as a member of the scheme your cover will begin from the date Irish Life accepts your application and you will be sent a formal acceptance letter confirming that you are a member of the scheme.

> Postponed - This means that due to you current medical circumstances, Irish Life cannot make a decision on your application but will review a new application form from you in a certain period of time eg 12 months. you will be sent a formal letter confirming your application has been postponed.

> Declined - This means that Irish Life is refusing your application for membership of the scheme. You will be sent a formal letter confirming your application has been declined.

If you application is postponed or declined, you can ask Irish Life to provide the reason for this decision, which may in certain circumstances be provided to you through your GP.

Completed forms should be returned to: Halligan Insurances, William Norton House, 575 North Circular Road, Dublin 1

In the interest of customer service, calls will be monitored.

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IMPORTANT DOCUMENTS

Eligibility Rules

Section 1: Personal Details

Section 2: Employment Details

Section 3: Doctor Details

Section 4: Medical and Other Important information

Your personal health information

Relevant Information

Genetic Test Information

Medical questions

Section 5: Declaration - You must read this carefully before signing

Electronic Signature Agreement

Section 6: Tele-interview - Your Questions Answered

Why are Tele-Interviews used?

Tele-interviews are used because:

Instruction

When will the tele-interview take place?

What do I need to prepare?

What if I do not wish to discuss my medical details over the phone?

What happens after the Tele-interview?

Section 7: Conﬁrmation of Scheme Membership

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