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    • In order to confirm our acceptance terms for eligible members into this scheme please complete the information below.
    • 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 http://www.irishlifecorporatebusiness.ie or you can ask us for a copy.

    • Group Life Cover Plan

    • We the Directors of this company confirm that the members listed below are permanent employees for the last two years and are under age 60. We also confirm they were actively at work or capable of being actively at work between the open window of 01/10/2020 and 31/10/2020 and have had not been absent from work due to illness or injury for more than 10 consecutive working days in the previous 4 weeks prior to the closing date of 31 October.
    • We also confirm that all members listed below are joining this scheme at their first available opportunity. Any members not joining the scheme at their first available opportunity must complete a standard application form.
    • *Actively at works means that the employee:
      (a) Is working their normal contracted number of hours.
      (b) Has not received medical advice to refrain from work
      (c) Is not restricted mentally or physically from fully performing the normal duties associated with their occupation.
      (d) 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
    • Note: Those on paid and unpaid Statutory leave (Maternity, Parental and Carer) can be considered actively at work so long as they would be able fulfil points b, c and d above.
    • NameDate of birthEmployment start date 
    • Warning: The current premium may increase after the new review 01/10/2021.

    • Declaration

    • I/We hereby agree that this application and declaration shall form the basis of the contract proposed between the Trustees and/or the Employers and Irish Life Assurance plc.

      I/We herby agree that all members who are eligible to join this scheme meet the actively at work requirements. I/We understand the answers to these questions are true and correct and this proposal will form the basis of the contract of insurance between Irish Life Assurance Plc, the Trustees (if this applies) and the employer

      If I/ We fail to reveal all the relevant information in relation to eligible members requesting to join their membership could be void.In the event of a claim proof of the members actively at work attendance information may be required.

      Relevant information is information which could affect Irish Life’s decision to accept this application for insurance. I understand that if I/We are in doubt as to whether any facts are relevant, I should tell Irish Life. I will add any information, on extra paper, which is relevant but it is not covered by the questions in this form.

      I confirm we have been informed about the Irish Life Data Privacy Notice and where to find it.

      I will advise all potential plan members of whose data we are providing to you of the availability of the Irish Life Data Privacy Notice.
    • Date Format: DD slash MM slash YYYY
    • Signed on behalf of Trustees

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    • Date Format: DD slash MM slash YYYY