In order to confirm our acceptance terms for eligible members into this scheme please complete the information below.

IMPORTANT DOCUMENTS

Important Documents End

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

Unique ID

Company Name*

Company Email*

Company Address*

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Company Address

Please select if you are a Limited or Non-Limited Company*

Limited Company

Non-Limited Company

We, the Directors of this company confirm that the members listed below are either the owner or an employee of the company 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 01/10/2021 and 31/10/2021 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 2021.

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 to fulfil points b, c and d above.

Employee's on Cover

Employee Name	Date of Birth	Cover	Employment Start Date	Actions
				Edit Delete
There are no Employees.

Maximum number of employees reached.

Annual Premium*

Warning: Kindly note that the premium may increase after the new review 01/10/2023.

Please choose a payment method

How do you want pay?*

by Credit Card

by Direct Debit

Note: You will be redirected to a payment portal to complete payment after you have submitted this application.

DD Payment Breakdown

Your Premium will be collected quarterly.

Your deductions will start on this date

We will collect this amount on each deduction

Declaration

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

Q1*

1) 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 confirm *

Q2*

2) I/We herby agree that all members who are eligible to join this scheme meet the actively at work requirements.

I confirm *

Q3*

3) 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 and the employer.

I confirm *

Q4*

4) 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.

I confirm *

Q5*

5) When deciding whether to insure the members listed on this application form and when setting their terms Irish Life will rely on the information you have given us. You must answer all questions that Irish Life have asked on this form honestly and with reasonable care. Where Irish life ask you to answer a specific question the subject matter of the question is relevant to the risk we the Insurer are being asked to undertake. If your answers are not true and complete, Irish Life may be entitled to:
> Cancel the members membership and benefits under the Scheme without a return of premium.
> Refuse 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.

I confirm *

Q6*

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

I confirm *

Q7*

7) I/We will advise all potential plan members of whose data we are providing to you of the availability of the Irish Life Data Privacy Notice.

I confirm *

Signed on behalf of Company*

Company Signed Date*

Name of Company*

Signed on behalf of Trustees

Trustee Signed Date*

Name of Trustee*

Address of Trustee*

Complete the Direct Debit Mandate

By signing this mandate form, you authorise (a) Halligan Insurances to send instructions to your bank to debit your account and (b) your bank to debit your account in accordance with the instruction from Halligan Insurances. As part of your rights, you are entitled to a refund from your bank under the terms and conditions of your agreement with your bank. A refund must be claimed within 8 weeks starting from the date on which your account was debited. Your rights are explained in a statement that you can obtain from your bank.

Creditor’s Details:
Halligan Life & Pensions Ltd - Creditor’s ID No: IE95SDD303969
William Norton House, North Circular Road, Dublin 1. Ireland.

IBAN*

BIC*Bank Identifier Code

Account Holder's Signature*

ISME Deed of Adherence

ISME act as the Trustees for this scheme and have executed the relevant Declaration of Trust.
Each ISME affiliated company has to adhere to this Trust in order to avail of the scheme.
Please complete the Deed of Adherence set out below.

This Deed of Adherence is made on the

Between (Company Name)

(hereinafter called “the Adhering Company”)

Whose registered address is

of the one part,

and ISME Limited and ISME Association (hereinafter called “The Association”) whose registered office is at 17 Kildare Street, Dublin 2, of the other part,

Whereas

A. This deed is supplemental to a Declaration of Trust dated the 13th day of August 2000 (hereinafter called “the Declaration”) made by the Association establishing THE ISME Group Life Assurance Scheme(hereinafter called “the Scheme”) for providing relevant benefits (as defined in Section 770 of the Taxes Consolidation Act) for certain employees (hereinafter called “The Members”) in accordance with the provisions of the Declaration and of the Rules to be adopted in accordance with the Declaration(hereinafter called “the Rules”).

B. The Association is the present Trustee of the Scheme.

C. The Adhering Company is an Associated Employer as defined in the Declaration and desires that its employees shall be enabled to become members and has agreed with the Association to undertake such liability in respect of contributions to the fund of the Scheme and such other liabilities as is or will be expressed in the Declaration and/or the Rules and the Association has further to that undertaking agreed to admit those of the adhering company’s employees as qualify under the Rules to be Members.

NOW THIS DEED WITNESSES and it is hereby agreed and declared as follows:

1. The Adhering Company with the approval of the Association hereby undertakes and covenants with the Association to pay contributions to the Association as Trustee in accordance with the Declaration and Rules with effect from the 1st day of October 2021.

2. The Adhering Company and the Association hereby covenant with each other to perform and observe the agreements and stipulations contained in the Declaration and Rules so far as they are or ought to be performed or observed by them respectively but so that no personal liability shall attach to the Association as Trustee except in respect of acts of negligence of defaults in relation to the trusteeship.

3. The Adhering Company has been advised that a copy of the Declaration of Trust is available at ISME offices.

In witness whereto the parties hereto have executed these presents at the date above first written.

Name of Adhering Company

Signed by Director/Secretary*

Data Protection Agreement

We comply with the provisions contained in the Data Protection Acts 1988 to 2018. We are committed to protecting and respecting your privacy. All calls, both inbound and outbound, may be recorded or monitored for quality, training and verification purposes.

Data collected to bind your policy is passed by secure email in encrypted form within the meaning of the Act and GDPR, you have the right to request a copy of your details we hold on file and to change any inaccuracies or to cancel same unless we are legitimately obliged to retain same.

If any doubt arises, contact info@halligan.ie

Accept the Data Protection Statement*

I confirm that I have read and accept the Data Protection Statement*

Electronic Signature Agreement*

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

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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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Completed Application Form

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Completed Deed of Adherence

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DigitalTag_Member

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CheckSum

Upload Your Profile

IMPORTANT DOCUMENTS

Important Documents End

Group Life Cover Plan

Please choose a payment method

DD Payment Breakdown

Declaration

Complete the Direct Debit Mandate

ISME Deed of Adherence

Data Protection Agreement

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